asaydental.com - Medical History

PATIENT DENTAL HISTORY
When was your last cleaning?

MonthDayYear
Date
When was your last set of X-rays taken?

MonthDayYear
Date
Please check any of the following that apply to you:

Tooth SensitivityHead/Ear/Neck painJaw joint painTeeth or fillings breakingBleeding/swollen/irritated gumsWisdom teeth removedLoose, tipped, or shifting teethSores or lumps in or near mouth
Do you have or have you ever had any of the following:

Partial DenturesOrthodonticsPeriodontal (gum) disease
PATIENT MEDICAL HISTORY
Are you under a physician’s care now?

YesNo
Why?
Have you been hospitalized in the last 5 years?

YesNo
Why?
Are you currently taking any medications?

YesNo
What?
Have you ever taken any Bisphosphonates for osteoporosis? (ie, Fosomax, Aredia, Zometa, etc)

YesNo
Do you smoke or use tobacco?

YesNo
For women only
Are you pregnant or trying?

YesNo
Are you taking birth control pills?

YesNo
Are you nursing?

YesNo
Type a question

AIDS/HIVAnaphylaxisAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseCancerChemotherapyChest PainsCold SoresCongenital Heart DisorderConvulsionsDiabetesDrug AddictionEmphysemaEpilepsy/SeizuresFainting SpellsGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart Pace MakerHeart Trouble/DiseaseHepatitis AHepatitis B or CHigh Blood PressureHypoglycemiaKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseParathyroid DiseasePsychiatric CareRadiation TreatmentRecent weight lossRheumatic FeverSinus TroubleStomach DiseaseStrokeSwelling of limbsThyroid DiseaseTuberculosisYellow Jaundice
Are you allergic to any of the following?

AspirinPenicillinCodeineMetalLatexLocal AnestheticsSulfa DrugsOther
PATIENT AUTHORIZATION AND RELEASE

I authorize Dr. Asay and/or associates or assistants as he may designate to perform those procedures as may be deemed necessary or advisable to maintain my or my dependent’s dental health including arrangement and/or administration of local anesthetic may cause an untoward reaction or side effects, which may include, but not limited to bruising, hematoma, cardiac stimulation, ad temporary or rarely permanent numbness. I voluntarily assume all possible risks, include the risk of harm, if any, which may be associated with dental procedures in hopes of obtaining desired results, which may or may not be achieved, for my or my dependent’s benefit. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions.
SIGNATURE OF PATIENT/GUARDIAN

Clear
DATE

MonthDayYear
Date
Should be Empty:

PATIENT DENTAL HISTORY

PATIENT MEDICAL HISTORY