Patient Registration

At Oral Surgery & Implant Centers, we offer patients a friendly and tranquil experience in a truly state of the art facility. It is our goal to treat each of our patients with the highest caliber of care and respect. We believe that quality counts and that details matter.

Please fill out the following Patient Health History form in its entirety, or, if you prefer, download the form by clicking on the link at the bottom of the page, then print and complete the form in its entirety to bring with you to your appointment. This will help to decrease the time you spend in our office filling out paperwork.

Patient Name: Email:

Date of Birth: Age: Height: Weight:

The detailed health history is very important for our staff to have as an aid in your treatment. If you do not have a positive answer simply write no. Please answer ALL questions completely. A yes answer may require some explanation. A nurse will be pleased to help you with any questions that you may have regarding this health history form. Thank you.

MEDICAL

Have you been examined by a physical within the past year?

For what reason?

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

If yes, please explain

Are you currently being treated by a physician for a medical problem?

If yes, please explain

Please list any prescribed medication taken within the past year:

Please list any medications that you are now taking:

Have you ever been seriously ill and/or hospitalized?

If yes, please list dates and reasons for all hospital admissions:

Have you had radiation treatment for any tumor or growth?

Do you often feel fatigued or tired?

Do you have Diabetes? Date of onset: Controlled?

Medications:

Have you ever had any of the following conditions? Please list dates or respond with "No":

Arthritis Colitis Epilepsy Jaundice

Multiple Sclerosis Thrombophlebitis Stomach Ulcers

Have you ever had or been exposed to any of the following communicable diseases? Please list dates or respond with "No":

Mononucleosis Hepatitis Herpes Venereal Disease

HIV Tuberculosis

Have you ever received a blood transfusion, platelets, or plasma?

CARDIOVASCULAR

Do you have or have you been treated for chest pain (angina)?

Do you have high blood pressure?

Have you ever had a heart attack or stroke (CVA or TIA)?

Have you ever had an irregular heart beat?

Have you ever had Rheumatic fever?

Do you have a heart murmur or any heart defect?

Have you ever heen told you needed to take an antibiotic before dental work?

Do you take any medication to prevent clotting?

Do you have any blood disorder such as anemia (thin blood)?

Have you ever been treated for any vascular problems?

Have you ever had an excessive bleeding problem?

Have you ever taken Fen Phen?

Do your ankles ever swell?

Have you ever had open heart surgery? or angioplasty? or angiogram?

RESPIRATORY

Do you have a persistent cough?

Are you ever short of breath with mild exertion?

Do you have asthma?

Do you have emphysema?

Do you have bronchitis?

Have you ever been a heavy smoker?

ALLERGIES

Have you ever experienced an unfavorable reaction to any of the following medications or foods? If yes, please indicate the type of reaction, or respond with "No":

Latex Penicillin

Erythromycin Codeine

Aspirin Versed

Propofol Talwin

Atropine Sodium Brevital

Soybean Oil Egg

Lecithin Glycerol

Any other medications

List food allergies or "None":

NEUROLOGICAL

Do you have numbness or tingling in any part of your body?

Has any part of your body ever been paralyzed?

Have you ever had a convulsion/seizure?

Do you have frequent?

Have you ever had psychiatric treatment?

Do you have a tendency to faint?

Do you consider yourself to be a nervous person?

Have you ever suffered from a severe nervous exhaustion (breakdown)?

Do you often feel unhappy or depressed?

Do you often cry?

Do you have a profound fear of dental or oral surgery treatment?

DISABILITY

Do you wear contact lenses?

Do you use a hearing aid?

Are you disabled in any way?

If yes, please explain:

DENTAL

Have you had regular dental care?

Have you ever had an unfavorable reaction to a local anesthetic (Xylocaine or Novocain) or any other dental material?

Have you previously had Sodium Brevital or Propofol in an oral surgery office?

Have you ever had an injury to the face, jaw or neck?

Do you have difficulty in opening your mouth wide?

Have you ever been diagnosed as having TMJ Syndrome or does your jaw joint ever "click", "pop" or have sharp pain or discomfort?

Have you had orthodontic care?

Would you like a referral to a general dentist or orthodontist for further care?

Are you currently experiencing dental pain or swelling?

PERSONAL

Do you currently smoke or use tobacco?

Number of years? How many packs a day?

Do you drink alcohol? How frequently?

Do you have a history of drug abuse or have you been addicted to any drug?

Are you currently involved in a substance abuse program?

How do you consider your health to be? Please choose one: Excellent, Good, Average, Fair or Poor

FOR LADIES ONLY

Are you pregnant? If yes, what trimester?

Are you currently taking birth control pills?

Have you passed through menopause?

Have you had a hysterectomy or ovariectomy?

ANESTHESIA

For the purpose of the proposed surgical procedure, which do you prefer?

Please choose one: Local Anesthesia (Xylocaine or Novocain), Local Anesthesia and Nitrous Oxide (laughing gas), I.V. Sedation, Deep Sedation/General Anesthesia

GENERAL

Please indicate any important medical or dental information not already covered by this questionnaire


By submitting this form, you release this information to Heritage Oral Surgery & Implant Centers to be used as is outlined in our Privacy Policy, and you acknowledge that the information submitted is true and correct to the best of your knowledge.