3834 Peachtree Rd NE
Atlanta, GA 30319

Call us today
404-237-0319

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family dentist

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ABOUT
SERVICES
NEW PATIENTS
- Fill Out Forms Online
CONTACT US
- Email Us
- Get Directions

Fill Out Forms Online

To Our New Patients
Welcome to our office. We appreciate your confidence in selecting us to care for your teeth. We will do our best to make your appointments as pleasant and convenient as possible. If at any time you have any questions regarding your treatment, appointments, or fees, please feel free to ask.
Patient's Name
First Last
Date Of Birth
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Email
Home Phone
Cell Phone
Occupation
Who Referred You?
Employed By
Work Phone
Spouse Employed By
Work Phone
Do You Have A Particular Dental Problems Or Discomfort?
When Was Your Last Dental Visit? Were Dental X-rays Taken ?
Do You Feel The Quality Of Your Dental Care In The Past Has Been
- Excellent
- Good
- Fair
- Poor
Do you have any pain in any part of your mouth or teeth while biting or chewing?
- Yes
- No
Do you chew on only one side of your mouth?
- Yes
- No
Do your gums bleed while chewing, brushing, flossing or at any other time?
- Yes
- No
Do your gums hurt or are they swollen?
- Yes
- No
Does food catch between your teeth?
- Yes
- No
Have you ever had any gum or bone treatment by a periodontist?
- Yes
- No
Have you ever had your bite adjusted or your teeth ground?
- Yes
- No
Have you ever worn braces or orthodontics?
- Yes
- No
Do you clinch or grind your teeth while awake or asleep?
- Yes
- No
Does your jaw or jaw joint make noises, pop, or hurt when you open or close?
- Yes
- No
Are you pleased with the appearance of your teeth?
- Yes
- No
Is there anything about dental treatment that bothers you?
- Yes
- No
Medical History
1. Have you been a patient in the hospital during the past two years?
- Yes
- No
2. Have you been under the care of a medical doctor during the past two years?
- Yes
- No
Physician's Name
Phone Number
3. Are you now taking any medication, pills, or drugs?
- Yes
- No
If yes, please list:
4. Are you allergic or have you reacted adversely to any of the following medications?
- Aspirin
- Nitrous Oxide
- Valium
- Novacaine
- Darvon
- Erythromycin
- Scopolamine
- Xylocaine
- Codeine
- Tetracycline
- Penicillin
- Demerol
- Percodan
- Other Antibiotics
- Sulfa
5. Are you aware of being allergic to any other medications or substances?
- Yes
- No
6. Check any of the following which you have had or have at present:
- Heart Failure
- Heart Disease or Attack
- Angina Pectoris
- High Blood Pressure
- Heart Murmur
- Rheumatic Fever
- Congenital Heart Lesions
- Scarlet Fever
- Artificial Heart Valve
- Heart Pacemaker
- Heart Surgery
- Artificial Joints (Hip, Knee)
- Anemia
- Stroke
- Kidney Trouble
- Ulcers
- Cosmetic Surgery
- Emphysema
- Cough
- Tuberculosis (TB)
- Asthma
- Hay Fever
- Sinus Trouble
- Allergies or Hives
- Diabetes
- Thyroid Disease
- X-Ray or Cobalt Treatment
- Fever Blisters
- Arthritis
- Rheumatism
- Cortisone Medicine
- Glaucoma
- Pain in Jaw Joints
- Tobacco Habit
- AIDS / HIV
- Hepatitis A (infectious)
- Hepatitis B (serum)
- Liver Disease
- Yellow Jaundice
- Blood Transfusion
- Drug Addiction
- Hemophilia
- Venereal Disease
- Cold Sores
- Chemotherapy (Cancer)
- Epilepsy or Seizures
- Fainting or Dizzy Spells
- Nervousness
- Psychiatric Treatment
- Sickle Cell Disease
- Bruise Easily
7. When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, or shortness of breath, or because you are tired?
- Yes
- No
8. Do your ankles swell during the day?
- Yes
- No
9. Do you use more than two pillows to sleep?
- Yes
- No
10. Has your medical doctor ever said you have cancer or tumor?
- Yes
- No
11. Please list any disease, condition or problem you have not noted above:
Women
Are you pregnant?
- Yes
- No
Are you taking birth control pills:
- Yes
- No
Have you ever taken IV Bisphosphonates?
- Yes
- No
In case of emergency, whom may we contact?
Name
Phone Number
Relationship to Patient
Please check the method of payment most convenient for you to use:
Payment At The End Of Each Visit
Bank Charge Card
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Nick Smith DDS PC Restorative Dentistry
Providing Quality General Dentistry in Atlanta, GA, since 1975

3834 Peachtree Rd NE | Atlanta, GA 30319 | Office: 404-237-0319 | drnick3834@gmail.com | Get Directions

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