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Medical History

Thank you for taking the time to fill this form out. This is a secure and private site, and your form results will be directly sent to our Mexico dental office. It is imperative that you list any health conditions and all medications prior to your dental treatment.

Dental Patient Medical History

 

THE ANWERS TO THE FOLLOWING QUESTIONS HELP OUR DENTISTS EVALUATE YOUR GENERAL HEALTH PRIOR TO PROVIDING YOU WITH DENTAL TREATMENT.

PLEASE READ CAREFULLY AND ANSWER EACH QUESTION AS ACCURATELY AS POSSIBLE.

  1. In general, how is your present health?
  2. What month and year did you have your last physical examination?

Please check each of the following medical conditions that you currently have or had in the past. If you check any box please explain in the Additional Details box.

Heart Disease or Condition
Congenital Heart Disease
Hepatitis
Stroke
Frequent Chest Pain
Glaucoma
Tuberculosis
Cancer *please explain below
Prolonged or Unusual Bleeding
Fainting or Dizzy Spells
Genital Herpes
AIDS or AIDS Related Complex
Arthritis
Drug Addiction
Jaundice *other than at birth
Rheumatic Fever
Venereal Disease
Hay Fever
Hemophilia
Psychiatric Treatment
High Blood Pressure
Diabetes
Anemia
Radiation Therapy
Chemotherapy
Blood Transfusion
Implant Prosthesis
Sickle Cell Anemia
Heart Murmur
Use Recreational Drugs
Asthma
Angina Pectoris
Thyroid Disease
Emphysema
Bruise Easily
Epilepsy
Shortness of Breath
Ulcers
Swollen Ankles
Kidney Problems
Artificial Heart Valve
Liver Disease
Cold Sores
Unexplained Weight Loss
Have COPD or Lung Disease

 
Additional Details:

Please check Yes or No for the following questions. If you answer Yes to any question, please provide details in the Patient Comments box.

  1. Are you presently or have you been under the care of a physician during the past year? Yes       No
  2. Are you presently taking any medications? Yes       No
  3. Are you allergic to any medication or other materials? Yes      No
  4. Have you ever had a reaction to a local anesthetic? Yes      No
  5. Have you ever experienced any complications or illness following dental treatment? Yes      No
  6. Do you have any disease or health conditions not listed above? Yes      No
  7. Have you ever been told you were not eligible to be a blood donor? Yes      No
  8. Do you use tobacco? Yes      No (if yes, please check product and give frequency)
    SMOKE:
    Cigarettes
    Vapor Cigarettes
    Cigars
    Pipe
    SMOKELESS:
    Chewing Tobacco
    Snuff or “Dip”
    FREQUENCY:
  9. WOMEN ONLY: Are you or could you be pregnant? Yes      No
    (if yes, check which trimester) 1      2      3

Patient Comments:

TELL US ABOUT YOUR DENTAL HISTORY

Please check Yes or No for the following questions. If you answer Yes to any question, please provide details in the Patient Comments box.

  1. Do your gums presently bleed when you brush or floss your teeth? Yes      No
  2. Are you teeth sensitive to hot or cold liquids or food? Yes      No
  3. Are your teeth sensitive to sweet or sour liquids or food? Yes      No
  4. Do you presently feel pain with any of your teeth? Yes      No
  5. Do you presently have any sores or lumps in or near your mouth? Yes      No
  6. Have you ever had any head, neck or jaw injuries? Yes      No
  7. Have you ever experienced any of the following conditions in your jaw? Yes      No
    1. Clicking? Yes      No
    2. Pain (joint, ear or side of face)? Yes      No
    3. Difficulty in opening or closing your mouth? Yes      No
    4. Difficulty in chewing? Yes      No
  8. Do you have frequent headaches? Yes      No
  9. Do you clench or grind your teeth? Yes      No
  10. Do you frequently bite your lips or cheeks? Yes      No
  11. Have you ever had any difficulty with teeth extractions in the past? Yes      No
  12. Have you ever had any orthodontic treatment? Yes      No
  13. Have you ever had prolonged bleeding following teeth extractions? Yes      No
  14. Had you received instructions on how to brush your teeth? Yes      No
  15. Have you ever been given instructions on how to care for your gums? Yes      No

Patient Comments:

By my signature below, I acknowledge that I have fully read and understand the above medical history questions. In addition, to the best of my knowledge, I have accurately and completely answered the above questions. I further acknowledge that providing incorrect information and/or answers can be detrimental (risk) to my health.

Signed by:

Leave this empty:

Note: A copy of this completed form will be emailed to you for your records.

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54-A Avenida Aldea, Santa Fe, NM 87507 Phone 1-505-738-7770 Hours Monday - Friday, 9:00 AM - 5:00 PM MDT
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