San Diego Dentist Consultation & Forms

(619) 656-3100

Name

Date

Address

Phone

Physician's Name

Your Age:

Weight:

Height:

1 a. Has there been any change in your health within the past Year? YES NO

b. Have you gained or lost more than 15ibs. within the past year? YES NO

2. My last physical examination was on

3. Are you now under the care of a physician? YES NO

a. If so, what is the condition being treated?

4. Have you been hospitalized or had a serious illness or injury within the past Five(5) years? YES NO

a. If so, what was the problem?

5. Are you sensitive or allergic to Penicillin, asprin, codeine, Erythromycin, xylocaine or any other drugs or medicine? YES NO

a. If "YES" please list:

6. Have you been taking any medicines within the past year? YES NO

a. If "YES" please list:

7. Do you know or have you ever had any serious illness or conditions such as:

        Scarlet Fever YES NO
        Diabetes YES NO
        Rheumatic Fever YES NO
        Frequent YES NO
        Thyroid Condition or Goiter YES NO
        AIDS YES NO
        High Blood Pressure YES NO
        Arthritis YES NO
        Sickle Cell Anemia or Trait YES NO
        Stroke YES NO
        Psychiatric Problems YES NO
        Glaucoma YES NO
        Stomach Ulcers YES NO
        Hip Joint Surgery YES NO
        Anemia YES NO

Other:

8. Have you ever received radiation or surgical treatment for a tumor, growth, or other condition about your head, mouth, lips, or any other portion of your body, YES NO

Explain:

9. Have you ever had any lung disease or breathing difficulty?
( Asthma, Emphysema, Tuberculosis, Pneumonia)

10. Do you now have or have you ever had any heart trouble? YES NO

Heart Attack, Heart Failure, Coronary Insufficiency,
Coronary Occlusion, Artificial Heart Valves, Mitral Valve Prolapse, Heart Murmur, etc.

please enter Dates:

11. Have you had any excessive bleeding requiring special treatment? YES NO

Explain:

12. Has you doctor ever said you had liver disease, jaundice, or Hepatitis? YES NO

Explain:

13. Are you Pregnant? YES NO

How many months?

If no, are you taking Birth Control Medication? YES NO

14. Do you have any numbness or tingling in any part of your body? YES NO

15. Are you subject to any nervous disorders, fainting, or dizziness? YES NO

16. Do you smoke? YES NO

If "YES", How many packs per day? For how long

17. Do you now have a cold, cough, or chest congestion? YES NO How long?

18. Do you have a persistent cough? YES NO How long?

19. Do you have any chest pain on exertion? YES NO Frequency?

20. Do you have difficulty in opening your mouth wide? YES NO

Explain:

21. Do you now have or have you ever had sinus trouble? YES NO when?

22. Have you ever had any injury to your face, jaws, or neck? YES NO

23. Have you ever had cancer? YES NO

Explain:

24. Has you doctor ever said you had kidney or bladder diseases or infection? YES NO

Explain:

25. Do you wear contact lenses: YES NO

26. Do you have any loose or false teeth? YES NO

27. Have you used any non-perscription (Street Drugs) in the last 72 hours? YES NO

28. Have you ever had any serious trouble associated with any Previous dental treatment? YES NO

If so, explain:

29. Have you or has any one in your family ever had a serious reaction to a general anesthetic? YES NO

If so, explain:

30. Do you have any disease, condition, or problem not listed above that you think we should know about? YES NO

If so, explain:

31. Have you ever taken prescription medication for weight reduction (Diet Pills)? YES NO

If "YES", did you take any of the drugs listed below?

Fen-Phen (Fentluramine + Phentermine)

Pondimin (Fenfluramine) Redux (Dexfenfluramine)

32. If you have ever taken any of the above drugs, have you had an medical exam to insure that your heart valve and lung were not affected.
YES NO

I CONFIRM AS TRUE THE ABOVE HEALTH HISTORY INFORMATION

Signature _____________________ DATE_________________

MEDICAL HISTORY NOTES:

Please print this out and bring with you on your appointment and press the submit button.

	Tooth Extraction	TMJ Treatment
	Dental Implants	Tooth Fillings
	Partial Dentures	Crown & Bridge
	Root Canal	Dental Pathology
	Teeth Whitening	Dental Composite
	Porcelain Veneers

EASTLAKE DENTISTRY
2400 Fenton Street, Suite A100 Chula Vista,
CA 91914
(619)656-3100

Dr. San Aye Tin - Dentist
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