Montes De Oca, DMD

Certain illnesses and drugs may make it necessary to alter our treatment.

In order to provide the best possible oral healthcare you (or your child), it is necessary to have the following information:

1. Asthma, hay fever, sinusitis or other allergies*

YesNo

2. Allergy to penicillin, aspirin, local or general anesthesia, or other drugs:*

YesNoOther

3. Blood pressure or heart problems*

YesNo

4. Rheumatic fever or heart murmur*

YesNo

5. A pacemaker or open heart surgery*

YesNo

6. Diabetes, liver, kidney, thyroid, or lung problems*

YesNo

7. Ulcers or stomach problems*

YesNo

8. Hepatitis or Jaundice*

YesNo

9. Epilepsy or nervous disorders*

YesNo

10. Bleeding or clotting disorders*

YesNo

11. Arthritis*

YesNo

12. Venereal Disease or Herpes*

YesNo

13. Acquired Immune Deficiency Syndrome (AIDS)*

YesNo

14. Any other illness*

YesNoOther

15. Do wounds heal slowly or present complications?*

YesNo

16. Are you presently taking any medicine? Specify*

YesNoOther

17. Are you presently under the care of a physician?*

YesNo

18. Have you ever had a physical exam?*

YesNo

Date

19. Have you ever been hospitalized?*

YesNo

20. Have you had x-ray treatments or chemotherapy?*

YesNo

21. Are you presently on a diet?*

YesNo

22. Do you utilize any type of tobacco?*

YesNo

23. WOMEN - Are you pregnant?*

YesNo

Medical History

HAVE YOU EVER HAD OR HAVE:

Adult Dental History

Update: