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Medical History Form

 

The information provided on this form is important to your dental health. Please complete all of the questions to the best of your ability. If there have been any changes in your health, please tell us. Questions are welcome and appreciated.

 

The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

 

Patient Information

For the following questions, mark yes or no, whichever applies. Your answers are for our records only and will be considered confidential.

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Date: *

 

Date of birth: *

  

Patient Gender: *

  Male   Female  

Height:

Weight:

 
 

Health History

Are You in Good Health?

Yes No  

Has there been any change in your health in the past year?:

Yes No  

My last physical exam was on?

Are you currently under the care of a physician? If so, for what condition?:

Name of physician:

Address of physician:

Have you ever been diagnosed with a developmental disability?

Yes No  

Have you had any serious illness, significant operation or hospitialization within the past 5 years?:

Yes No  

Have you had joint replacement surgery (such as: knee, hip, etc) within the past 5 years?:

Yes No  

Are you taking any medication(s) including non-prescription, homeopathic or or natural remedies including diet pills? If so, please list:

 

Do you have any of the following diseases or problems?

High blood pressure, arteriosclerosis (high cholesterol)

Yes No  

Damaged heart valves, artificial valves or heart murmur

Yes No  

Rheumatic Heart Disease

Yes No  

Heart trouble, angina, stroke, heart attack, or any other heart conditions

Yes No  

Chest pain upon exertion

Yes No  

Shortness of breath after mild exercise

Yes No  

Do your ankles swell

Yes No  

 

Allergies

Yes No  

Asthma or hay fever

Yes No  

Diabetes Type I or II

Yes No  

Frequent of recurring mouth sores

Yes No  

Stomach ulcers or hyperacidity

Yes No  

Kidney trouble

Yes No  

 

Cancer

Yes No  

Respitatory problems, emphysema, bronchitis, COPD etc

Yes No  

Arthritis or panful, swollen joints including jaw joint (TMJ)

Yes No  

Persistent cough or cough that produces blood

Yes No  

Epilepsy or neurological disorder

Yes No  

Any disease, drug or transplant operation that has depressed your immune system

Yes No  

Sexually transmitted disease(s)

Yes No  

Sinus Trouble

Yes No  

 

Fainting spells or seizures

Yes No  

Hepatitis, jaundice or liver disease

Yes No  

Thyroid disease (hypo/hyper)

Yes No  

Tuberculosis

Yes No  

Low Blood Pressure

Yes No  

Persistent swollen neck glands

Yes No  

Have you had abnormal bleeding?

Yes No  

 

Have you ever required a blood transfusion?

Yes No  

Do you have any blood disorder such as anemia?

Yes No  

Have you ever had treatment for a tumor or growth?

Yes No  

Do you have a history of sleep apnea? Do you currently use a CPAP machine?

Yes No  

Are you currently taking or have you taken these medication(s) in the past: Bisphosphonate therapy such as Fosamax, Boniva, Zometa, Aclasta, Reclast

Yes No  

 

Are you allergic to or have you had a reaction to:

Local anesthetics

Yes No  

Penicillin or antibiotics

Yes No  

Sulfa drugs

Yes No  

Barbituarates or Sleeping pills

Yes No  

Asprin

Yes No  

Iodine

Yes No  

Codeine or other narcotics

Yes No  

Latex or rubber products

Yes No  

Other

Yes No  

 

Have you had any serious trouble associated with previous dental treatment? If so, explain:

Do you have any other condition or disease you think the doctor should know about? If so, explain:

Are you wearing contact lenses?

Yes No  

Are you wearing removable dental appliances?

Yes No  

 
 

Women

 

Are you pregnant or trying to become pregnant?

Yes No  

Do you have problems associated with your menstrual period?

Yes No  

Are you nursing?

Yes No  

Are you taking birth control pills?

Yes No  

 
 

IF YOU ARE USING ORAL CONTRACEPTIVES IT IS IMPORTANT YOU UNDERSTAND THAT ANTIBIOTICS & OTHER MEDICATIONS MAY INTERFERE WITH THE EFFECTIVENESS OF ORAL CONTRACEPTIVIES. THEREFORE, YOU WILL NEED TO USE MECHANICAL FORMS OF BIRTH CONTROL FOR ONE COMPLETE CYCLE OF BIRTH CONTROL PILLS AFTER THE COURSE OF ANTIBIOTICS OR OTHER MEDICATIONS IS COMPLETTED. PLEASE CONSULT WITH YOUR PHYSICIAN FOR FUTURE GUIDANCE.

 

IF YOU ARE PREGNANT, POSSIBLY PREGNANT, OR TRYING TO BECOME PREGNANT, SURGERY ANESTHETIC OR ANY OTHER MEDICATION MAY SIGNIFICANTLY HARM THE DEVELOPMENT OF YOUR BABY, ESPECIALLY DURING THE FIRST TRIMESTER. PLEASE ADVISE THE DOCTOR IF THERE IS ANY CHANCE OF YOUR BEING PREGNANT!

 

Chief dental complaint:

 

Certification of Information

 

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquireies set forth above have been answered to my satisfaction. I will not hold my dentist or any member of the staff responsibile for any errors or omissions that I may have made in the completion of this form.

 

Patient/Guardian:

DATE:

 
 

It may take a moment to submit your information. Please wait for a confirmation message.

 

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Office Location:

Joseph J. Radakovich, DMD
Providence Professional Plaza Building
5050 NE Hoyt St, Suite 322
Portland, OR 97213
Phone: 503-455-4673 Fax: 503-230-0344

Office Hours:

Monday, Tuesday & Thursday:
8:30AM to 4:30PM
Wednesday: 8:30AM to 3:00PM
Friday: 8:30AM to 2:00PM

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Joeseph J. Radakovich, DMD | www.radakovichoralsurgery.com | 503-455-4673
5050 NE Hoyt St, Suite 322, Portland, OR 97213



 

 

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Joeseph J. Radakovich, DMD, 5050 NE Hoyt St, Portland, OR, 97213 - Related Phrases: oral surgeon Portland OR \ maxillofacial surgeon Portland OR \ oral surgeon Portland OR \ 503-455-4673 \ www.radakovichoralsurgery.com \ 11/19/2017