Smile 4 Ever Medical History

Medical History Form

Zona Urbana Rio Tijuana, 22010 Tijuana, BC, Mexico Tel US (619) 906-7481
The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health.

INSTRUCTIONS: Please fill the form in all the fields that aply, also don’t forget to X the corresponding check boxes, once done click submit and email the PDF form to contact@smile4evermexico.com You will also need to print it, sign it and bring it with you to your appointment
ABOUT YOU
Date:*

MonthDayYear
Name:*
Email:*
example@example.com
Birthdate:*

MonthDayYear
Address:
Phone:*
MEDICAL HISTORY
Your health is very important to us, for all surgeries we a do complete blood work and urine analysis, if you have a condition or illness, you know about, make sure you fill out the form with that information, also, if you are taking any prescribed or nonprescribed medication make sure you let us know.
1. Are you currently under the care of a physician?*

YESNO
If yes please Explain:
For our records can you provide your doctor's Name:
Your Physician's phone:
2. Your current physical health is:*
3. Do you smoke or use tobacco in any form?*

YESNO
4. Have you had any metal rods, pins, or implants?*

YESNO
5. Are you taking any prescription/over the counter or herbal supplement drugs?*

YESNO
If so please list each one:
6. For Women: Are you using a prescribed method of birth control?

YESNO
Are you currently pregnant?

YESNO
Week of gestation #
7. Please list any serious medical condition(s) that you have ever had:
8. Why do you need dental services (explain)?
9. Do you require antibiotics before dental treatment?*

YESNO
10. Are you currently in pain?*

YESNO
11. Any nonprescribed controlled substance or medication you have recently used?*

YESNO
Which one(s)?
When was the last time you used?
12. Have you ever had a serious/difficult problem associate with any previous dental work?*

YESNO
Have you ever had periodontal or gum treatment?*

YESNO
13. Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD?)*

YESNO
14. Your current dental health is (explain):
15. Are you sensitive to heat, cold, or anything else?
16. Are you allergic to any of the following: (please check all that apply)

AspirinCodeineDental AnestheticsErythromycinLatexPenicillinTetracycline
Any other drugs/materials that you are allergic to:
Have you ever had any of the following diseases or medical problems:

Abnormal BleedingHIV+/AIDSAlcohol/Drug AbuseHospitalized for Any ReasonAnemiaKidney ProblemsArthritisLiver DiseaseArtificial Bones/JointsLow Blood PressureAsthmaLupusBlood TransfusionMitral Valve PressureCancer/ChemotherapyPacemakerColitisPsychiatric ProblemsCongenital Heart DefectRadiation TreatmentDiabetesRheumatic/Scarlet FeverDifficulty BreathingSeizuresEmphysemaShinglesEpilepsySickle Cell Disease/TraitsFainting SpellsSinus ProblemsFrequent HeadachesStrokeGlaucomaThyroid ProblemsHay FeverTuberculosis (TB)Heart AttackUlcersHeart SurgeryVenereal DiseaseHemophiliaHepatitisHerpes/Fever BlistersHigh Blood PressureOsteoporosis
ADITIONAL INFORMATION:
EMERGENCY INFORMATION
Emergency contact:*
Phone number:*
I understand that the information that I have given today is correct to the best of my knowledge. I understand that failing to provide accurate information may postpone or cancel my treatment or surgery. I also understand that this information will be held in the strictest confidence under patient/doctor privilege, and it is my responsibility to inform this office of any changes in my medical status.
Name:*
Signature:__________________________________________

(Print and sign manually)
Submit and email the PDF form to contact@smile4evermexico.com
Should be Empty:

Medical History Form

ABOUT YOU

MEDICAL HISTORY

EMERGENCY INFORMATION