Joseph Krajekian Medical/Dental Form

Patient Name

First NameLast Name

Age

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Office Where you are having procedure Performed

Overall Health Questions

Rows	Yes	No
Are you in good general health?
Have there been changes in your health within the last year ?
Recent Hospitalization ?
Currently under care of a physician ?
Have you had problem with dental treatment before ?
Are you currently having pain ?

Reason for hospitalization ?

reason for recent hospitalization

List of Medication you take. Name and Dose

Allergies to Medication or Food

Dental Questionnaire

Rows	Yes	No
Do you clench or grind your teeth?
Do you have popping or clicking in the jaw?
Have you had any injury to your face/jaw?
Do you have ringing of the ears?
Do you have TMJ disease?
Do you get headaches or migraines ?
Do you snore ?
Do you have sleep apnea ?

Have you experienced any of the following ?

Rows	Yes	No
Chest pain (angina)?
Swollen ankles?
Shortness of breath?
Recent weight loss, Fever, Night sweats?
Persistent cough, Coughing up blood?
Bleeding problems, bruising easily?
Difficulty swallowing?
Diarrhea, constipation, blood in stools?
Frequent vomiting nausea?
Difficulty urinating, blood in urine?
Dizziness?
Fainting spells?
Blurred Vision?
Seizures?
Joint pain?

Do you have or have you had

Rows	Yes	No
Heart disease
Heart attack
Heart murmurs
Rheumatic fever
Atrial fibrillation
High blood pressure
Stroke
Asthma, TB, Emphasyema
Hepatitis, Other liver diseases
Stomach Problems, Ulcers
Allergies to: food, drugs, medications, latex
Family History of diabetes, Heart problems, tumors?

Rows	Yes	No
Aids
Herpes
Tumors, Cancers
Eye Diseases
Skin Diseases
Anemia
Arthritis, Rheumatism
Kidney, Bladder diseases
Thyroid, Adrenal diseases
Diabetes
Psychiatric care
Radiation treatment to the head or neck
Chemotherapy
Prosthetic heart valve
Artificial Joint? When?
Contact lenses
Blood transfusions
Surgeries
Pacemaker
Obstructive sleep apnea

Do you have any other medical issues that have not been addressed above

Please read the following statements and sign when completed

Recreational drug use, overdose with medication, or excessive alcohol consumption can adversely affect liver function which is critical for producing blood clotting factors. Disclosure will allow your surgeon to safely treat you and prevent excessive post-surgical bleeding which can be life-threatening. Current recreational drug use: interaction with local anesthesia and IV sedation agents can be life-threatening. Full disclosure is critical for safe management.

Drug abuse history

How often do you consume alcoholic beverages?

Are you currently pregnant or trying to become pregnant?

Pregnancy : I understand that if there is a possibility of current pregnancy, surgery will be postponed (only IV Sedation/General Anesthesia) until I complete either a home or blood pregnancy test prior to scheduling IV sedation /general anesthetic procedure and report the results to my treating surgeon. Medication used during the surgery and post-operative period can adversely affect the developing baby.

Are you on birth control medication ?

Birth Control Pills: Antibiotics are commonly prescribed during your surgical management. Antibiotics can decrease the efficacy of the birth control pill leading to pregnancy. It is recommended that a second alternative form of birth control be used for the full cycle (month) if pregnancy is not desired.

Are you now or have you ever been treated with oral or intravenous bisphosphonates for Osteoporosis / Osteopenia/ Arthritis / Cancer Bone Metastases? Failure of the disclosure can lead to complications in bone healing (Osteonecrosis of the jaw bone) which are very difficult to treat.

Oral Form: Fosamax, Actonel, Skelid, Didronel, Boniva
Intravenous Forms : Zometa, Aredia

Are you using or have you ever used any of the oral or IV bisphosphonates?

I First Name Last Name acknowledge that I have answered every question thoroughly and accurately to the best of my knowledge.

Today's Date

Signature

Medical / Dental History

Drug and Alcohol

Women (only)

Medical Alert