History
PLEASE ANSWER ALL QUESTIONS. ANSWERS ARE FOR OUR RECORDS ONLY AND ARE CONFIDENTIAL.
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What is your name (First Last)? *
What is your birthdate? *
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DD
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YYYY
What is your age? *
What is your Sex? *
Required
What is your height? (ft., inches) *
How much do you weigh (lbs.)? *
Are you in good health? *
Required
Your last physical exam was on? *
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/
DD
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Are you under the care of a physician? *
If so, what condition(s) are being treated? (If answer above was no, write "none") *
Name and telephone number of the physician *
Have you had any serious illness, operation or been hospitalized? *
Required
If so please describe and include dates (If answer above was no, write "none") *
Do you drink alcoholic beverages? *
Do you smoke cigarettes, marijuana? *
Have you ever used recreational drugs (ex. Cocaine,Meth)? *
Last used? ( Cocaine, Meth, Marijuana etc)(If answer above was no, write "no") *
Have you had abnormal bleeding or bruising associated with previous extractions, surgery or trauma? *
Have you had a blood transfusion? *
Why?
Are you taking ANY of the following? *
Yes
No
PAIN MEDS (ex. Norco, Percocet, Codeine, etc)
Antibiotics (ex. Amoxicillin, Z-Pak, Clindamycin)
Anticoagulants/blood thinners (ex. Plavix, Coumadin, Pradaxa, Xeralto, Eliquis)
Blood pressure, Heart pills, Nitroglycerin
Cortisone (steroids)
Insulin, or Diabetes medication
Diet pills, now or in the past, (ex. Fen-Phen, Phentramine, Redux, Dexfenfluramine)
Have you ever taken Bisphosphonate pills or injectables for osteoporosis or chemotherapy (ex. Fosamax, Actonel, Aredia, Boniva, Reclast)? *
If yes, for how long? Last dose? (If answer above was no, write "no") *
Have you ever had radiation therapy to the head, neck, or lungs? *
Why, when?
Are you pregnant? Are you nursing? *
Do you have TMJ (jaw joint) problems (clicking, popping, or limited opening)? *
Do you have dentures, loose crowns, temps? *
Have you ever been told you need to take antibiotics before dental surgery? *
If yes, Why? (If answer above was no, write "no") *
Any adverse reactions or complications with prior dental, surgical or medical treatment? Any anesthesia complications (family history)? *
If yes, explain? (If answer above was no, write "no") *
Are you ALLERGIC or have you reacted adversely to: *
Yes
No
Penicillin, Clindamycin, other antibiotics
Local Anesthetic (Lidocaine, Novocaine)
Pain pills (Norco, Percocet, Codeine, Vicodin)
Barbiturates, sedatives, sleeping pills
Aspirin, NSAIDS (Motrin, Aleve, Ibuprofen)
Egg, Soybean, Seafood, Shrimp, Iodine
Latex
Heart *
Yes
No
High Blood Pressure, High Cholesterol
Chest Pain, Angina, Heart Attack
Heart Failure, Coronary Artery Disease
Heart Murmur, Irregular Heart Beat
Heart Surgery (Bypass, Stents, Valves, etc.)
Stroke, TIA’s, Fainting Spells
Rheumatic Fever, Heart Damage
Family History of Heart Disease
Lungs *
Yes
No
Asthma, Bronchitis
Emphysema, COPD
Lung Disease, TB, Chronic Coughing
Cough, Congestion or Fever in the past 4 weeks?
Liver *
Yes
No
Hepatitis, Cirrhosis, Liver Disease/Cancer
Kidney *
Yes
No
Kidney Disease, Dialysis
Gastrointestinal/ Stomach *
Yes
No
GERD/ Stomach Ulcers
Gastrointestinal disease/Cancer
Endocrine *
Yes
No
Diabetes-Insulin or Non-insulin dependent
Thyroid Disorders, Tumors, or Cancer
Blood *
Yes
No
Anemia, Hemophilia
Bleeding Disorders(Or any Family History)
Skeletal *
Yes
No
Arthritis
Osteoporosis
Artificial Joint Replacement
Other *
Yes
No
Allergies
History of Seizures, Epilepsy
Mental disorders(Anxiety, Depression, ADD)
Cancer of any type
SLEEP APNEA, Heavy Snoring
Malignant Hyperthermia (any Family History)
HIV, AIDS, T-cell count
Any type of Sexually Transmitted Diseases
Autoimmune Disorders
Glaucoma
History of any Organ Transplant
Eating Disorders
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This form was created inside of Mountain West Surgery and Sedation.