Fallston Dental Care

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     Patient's Name:               Date of Birth:

      Dental History                                                                               

    1.

How long since your last dental/professional cleaning?                                                                           

                           

 

Previous dentist's name:                                                                              Phone#:       

 

    2.

Were dental x-rays taken?                              How long ago?                 

 

    3.

Have you ever had gum (perio) or orthodontic treatment?        What?           When?

     

 

 

 

       Medical History 

    1.

Are you under a physician's care?       For what?                                                

                         

 

Physician's Name:                                                                                   Phone: 

 

    2.

Do you require antibiotics prior to dental treatment from you Cardiologist or Orthopedic Surgeon or any physician?  If yes......

 
  Doctor:                                                                                               For What?  
    3.

Have you ever been told you might have any heart disease?

CIRCLE ANY:          PACEMAKER        OR        ARTIFICIAL HEART VALUE       OR         HEART MURMUR

 
    4. Do you have any artificial joints/prosthesis or replacements?         Where?                                 When?  
    5.

Are you taking any MEDICATIONS?  If yes,  List medications:

 

 
    6. Are you ALLERGIC to any MEDICATIONS?       What?   
    7. Do you routinely take vitamins or herbal substances?  What?       
    8. Are you pregnant or suspect you may be? Y          N
    9. Do you have high or low blood pressure?  If so, which? Y          N 
   10. Had radiation/chemo treatment for tumor or growth? Y          N
   11. Do you have inflammatory diseases, such as arthritis or rheumatism? Y          N
   12. Do you have any auto immune disorders , ex:  Lupus, Fibromyalgia, or Chronic Fatigue, Sjogrens? Y          N
   13. Do you have any blood disorders, such as anemia, leukemia, or excess bleeding, etc?  Y          N
   14. Do you have any stomach, kidney, or liver problems? Y          N   
   15. Are you diabetic?  Y          N 
   16. Do you have asthma?  Y          N
   17. Do you have epilepsy or seizure disorders?  Y          N
   18. Do you have or have you had STD, VD, AIDS or  tested HIV positive?  Y          N    
   19. Do you have or have you had Vertigo or any inner ear problems? Y          N      
   20. Have you had or do you test positive for hepatitis?     If yes, when? Y          N 
   21. Do you or have you had Tuberculosis? Y          N
   22. Do you or have you ever used tobacco?         What?                                                        When?  
   23. Any dental anxiety, phobia, or problem not listed?  If so, explain?   
   24.

Any Mental Health issues or Learning Disabilities or Physical Disabilities? 

Explain:

 
   25.

What would you like to change about your smile?

 

 
   26.

Any areas which were not mentioned above but you feel we should know?

 

 
     
     

    Please note our posted Personal Health Information Privacy Policy.  In accordance with HIPAA regulations we will use your personal health

    information for treatment, payment for services, and/or healthcare operations.  List who in your family we may discuss this information with:

    Name:____________________________________________Relationship:____________________________Date__________

    Name:____________________________________________Relationship:____________________________Date__________

    Guarantor (if minor) Signature_____________________________Print Name__________________________ Date__________