Montes De Oca, DMD - Family Dentistry
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  • Montes De Oca, DMD

    Family Dentistry
  • Date of your appointment*
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  • Birthdate*
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  • Sex
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  • Medical History

  • 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:

  • HAVE YOU EVER HAD OR HAVE:

  • 1. Asthma, hay fever, sinusitis or other allergies*
  • 2. Allergy to penicillin, aspirin, local or general anesthesia, or other drugs:*

  • 3. Blood pressure or heart problems*
  • 4. Rheumatic fever or heart murmur*
  • 5. A pacemaker or open heart surgery*
  • 6. Diabetes, liver, kidney, thyroid, or lung problems*
  • 7. Ulcers or stomach problems*
  • 8. Hepatitis or Jaundice*
  • 9. Epilepsy or nervous disorders*
  • 10. Bleeding or clotting disorders*
  • 11. Arthritis*
  • 12. Venereal Disease or Herpes*
  • 13. Acquired Immune Deficiency Syndrome (AIDS)*
  • 14. Any other illness*

  • 15. Do wounds heal slowly or present complications?*
  • 16. Are you presently taking any medicine? Specify*

  • 17. Are you presently under the care of a physician?*
  • 18. Have you ever had a physical exam?*
  • Date
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  • 19. Have you ever been hospitalized?*
  • 20. Have you had x-ray treatments or chemotherapy?*
  • 21. Are you presently on a diet?*
  • 22. Do you utilize any type of tobacco?*
  • 23. WOMEN - Are you pregnant?*

  • Adult Dental History

  • Date of Last Dental Exam
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  • Date of Last Full Mouth X-Ray
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  • 1. Have you had trouble from previous dental care?*
  • 2. Do you have pain in your jaw or near your ears?*
  • 3. Do you have any unhealed injuries or inflamed areas in or around your mouth?*
  • 4. Have you experienced any growths or sore spots in your mouth?*
  • 5. Does any part of your mouth hurt when clenched?*
  • 6. Have you ever had Novocain or other local anesthetic?*
  • 7. Have you ever had Nitrous Oxide (laughing gas)?*
  • 8. Have you ever had general anesthesia?*
  • 9. Have you ever had any reaction or allergic symptoms to Novocain, local or general anesthetics?*
  • 10. Have you ever had any difficult extractions in the past?*
  • 11. Have you ever had prolonged bleeding following extractions in the past?*
  • 12. Do your gums bleed?*
  • 13. Do you have a bad taste in your mouth or mouth odor?*
  • 14. Have you had instructions on how to take care of your gums?*
  • 15. Do you chew with only one side of your mouth? if so why?*

  • 16. Do you often clench or grind your teeth during the day or night?*
  • 17. Is any part of your mouth sensitive to pressures or irritants (hot, cold or sweets)?*
  • 18. Is there any problem not mentioned above that you would like to discuss?*

  • Date*
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  • Update:

  • Date:
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  • Date:
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  • Should be Empty: