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Welcome
The Valley Dental Team
New Patients
About You Form
Patient Medical History
Patient Registration Form
Office Financial Policy
Patient Consent Form
Financing
Contact Us
Although dental personnel primarily treat the area in and around the mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following confidential questions.
Name
*
First
Last
Date of Birth
*
Are you under a physician's care now?
*
Yes
No
Have you ever been hospitalized or had a major operation?
*
Yes
No
Have you ever had a serious head or neck injury?
*
Yes
No
Are you taking any medications, pills or drugs?
*
Yes
No
Please list any medications, pills or drugs:
Do you take, or have you taken, Phen-Fen or Redux?
*
Yes
No
Are you on a special diet?
*
Yes
No
Do you use tobacco?
*
Yes
No
Do you use controlled substance?
*
Yes
No
Women: Are you pregnant/trying to get pregnant?
Yes
No
Women: Are you taking oral contraceptives?
Yes
No
Women: Are you nursing?
Yes
No
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Please check ones that apply.
If you have, or have had, any of the following please check:
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artifical Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rhematism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
Please check ones that apply.
Comments
If you have had any serious illnesses not listed above or put yes for any questions please explain here.
Signature
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Date
Date Format: MM slash DD slash YYYY
Welcome
The Valley Dental Team
New Patients
About You Form
Patient Medical History
Patient Registration Form
Office Financial Policy
Patient Consent Form
Financing
Contact Us
Valley Dental
1637 Main St
Onalaska, WI 54650
Phone:
(608) 781-3999