Welcome to our Dental Office
The personal information provided below will be protected and keep private by our office. All information will be used and disclosed responsibly according to the Privacy Act standards set up and monitored by our office.
The following information is required by the dentist to assist in proper diagnosis and treatment
1. Have you ever had a serious illness requiring hospitalization or extensive medical care?
Yes
No
Please specify
2. Are you presently under the care of a physician?
Yes
No
If so, please explain
3. Have you had a medical examination in the last year?
Yes
No
4. Do you use any prescription or non-prescription drugs regularly?
Yes
No
Please specify
5. Do you have any allergic conditions: e.g. hay fever, skin rash, food allergies, metal, latex?
Yes
No
6. Do any allergic reactions result in headaches, shortness of breath, chest constriction, nausea?
Yes
No
Please specify
7. Have you been hospitalized in the last 5 years?
Yes
No
Please specify
8. Have you ever experienced any unusual reaction to any of the following?
Yes
No
local anaesthesia (freezing)
aspirin
penicillin
codeine
sulpha drugs
barbiturates (sleeping pills)
or any other medicine?
If so please explain
9. Have you been warned against taking any drug or medication?
Yes
No
10. Do you bruise easily or bleed abnormally?
Yes
No
11. Do you require pre-medication for dental treatment?
Yes
No
12. Have you ever had any organ implants or medical implants?
Yes
No
13. Have you ever fainted?
Yes
No
14. Do your ankles swell?
Yes
No
15. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?
Yes
No
16. Do you have frequent headaches?
Yes
No
17. Do you have A.I.D.S. or have you ever tested positive for H.I.V.?
Yes
No
19. Have you had any injury, surgery or x-ray therapy to your face OF jaws?
Yes
No
20. Do you have any disease, condition, or problem that you think the doctor should know about?
Yes
No
21. WOMEN ONLY
Are you pregnant or suspect you might be? If so, what month are you in?
Yes
No
Are you taking birth control pills?
Yes
No
Are you nursing?
Yes
No
Dr. Lloyd G. Pedvis Dentistry Professional Corporation