NEW PATIENT FORM
For your convenience we have made the new patient forms available online.
Thank you! Nick Levi, DDS and staff.
Previous Dentist's Name
Have you noticed any
mouth odors or bad tastes?
Do you frequently get cold
sores, blisters or any other oral lesions?
A serious injury to the mouth or head?
Have your parents experienced
gum disease or tooth loss?
Headaches, neckaches or shoulder aches?
Have you noticed any loose teeth
or change in your bite?
Sore muscles (neck, shoulders, side of face)?
Does food tend to become
caught in between your teeth?
Clench or grind teeth while
awake or asleep?
Difficulty in chewing on either side of the mouth?
Difficulty in opening or closing the
Do you have tired jaws especially in the morning?
Date of last health care exam:
Hepatitis, Any Form (specify)
Other Infections (specify)
Are you allergic or have you had a reaction to:
Please list any medications you are currently taking:
None Slight Moderate High
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of change in my health and medication.