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Pay Online
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Office Hours Location
Book an Appointment
480-405-0300
4804050300
Home
About Us
Why Choose Our Office?
Meet the Doctor
Meet our Staff
Our Patient Reviews
Office Hours
Services
Cosmetic Dentistry
Dental Implants
Orthodontics
Veneers
Endodontics
Dentures
Same Day Cerec Crowns
Oral Surgery / Wisdom tooth removal
Whitening
GLO Professional Whitening
Full Mouth Reconstruction
Restorative Dentistry
Preventive Dentistry
Sedation Dentistry
Smile Gallery
Reviews
Patient Resources
Financing Options
Pay Online
Patient Connect Login
New Patient Paperwork
Blog
Contact
Book an Appointment
Office Hours Location
Medical History
Medical History
What is your estimate of your general health?
Excellent
Good
Fair
Poor
Do You Have or Have You Ever Had:
1. hospitalization for illness or injury
Yes
No
31. head or neck injuries
Yes
No
2. an allergic reaction to
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
metals (nickel, gold, silver, ____________)
latex
6. pacemaker or implantable defibrillator
Yes
No
3. heart problems, or cardiac stent within the last six months
Yes
No
33. neurologic disorders (ADD/ADHD, prion disease)
Yes
No
4. history of infective endocarditis
Yes
No
34. viral infections and cold sores
Yes
No
5. artificial heart valve, repaired heart defect (PFO)
Yes
No
35. any lumps or swelling in the mouth
Yes
No
6. pacemaker or implantable defibrillator
Yes
No
36. hives, skin rash, hay fever
Yes
No
7. orthopedic implant (joint replacement)
Yes
No
37. STI / STD / HPV
Yes
No
8. rheumatic or scarlet fever
Yes
No
38. hepatitis
Yes
No
9. high or low blood pressure
Yes
No
39. HIV / AIDS
Yes
No
10. a stroke (taking blood thinners)
Yes
No
40. tumor, abnormal growth
Yes
No
11. anemia or other blood disorder
Yes
No
41. radiation therapy
Yes
No
12. prolonged bleeding due to a slight cut (INR > 3.5)
Yes
No
42. chemotherapy, immunosuppressive medication
Yes
No
13. emphysema, shortness of breath, sarcoidosis
Yes
No
43. emotional difficulties
Yes
No
14. tuberculosis, measles, chicken pox
Yes
No
44. psychiatric treatment
Yes
No
15. asthma
Yes
No
45. antidepressant medication
Yes
No
16. breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
Yes
No
46. alcohol / recreational drug use
Yes
No
17. kidney disease
Yes
No
Are You:
18. liver disease
Yes
No
47. presently being treated for any other illness
Yes
No
19. jaundice
Yes
No
47. presently being treated for any other illness
Yes
No
20. thyroid, parathyroid disease, or calcium deficiency
Yes
No
48. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
Yes
No
21. hormone deficiency
Yes
No
49. taking medication for weight management
Yes
No
22. high cholesterol or taking statin drugs
Yes
No
50. taking dietary supplements
Yes
No
23. diabetes
Yes
No
51. often exhausted or fatigued
Yes
No
24. stomach or duodenal ulcer
Yes
No
52. experiencing frequent headaches
Yes
No
25. digestive disorders (i.e. celiac disease, gastric reflux)
Yes
No
53. a smoker, smoked previously or use smokeless tobacco
Yes
No
26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
Yes
No
54. considered a touchy / sensitive person
Yes
No
27. arthritis
Yes
No
55. often unhappy or depressed
Yes
No
28. autoimmune disease
Yes
No
56. taking birth control pills
Yes
No
29. glaucoma
Yes
No
57. currently pregnant
Yes
No
30. contact lenses
Yes
No
58. prostate disorders
Yes
No
List all medicatons, supplements, and or vitamins taken within the last two years.
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
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