About
Services
Patients
Payment
Blogs
Contact
Appointment Request
Menu
About
Services
Patients
Payment
Blogs
Contact
Appointment Request
About
Services
Patients
Payment
Blogs
Contact
Appointment Request
X
About
Services
Patients
Payment
Blogs
Contact
Appointment Request
Menu
About
Services
Patients
Payment
Blogs
Contact
Appointment Request
About
Services
Patients
Payment
Blogs
Contact
Appointment Request
X
Home
/
Medical History
Medical History
First Name
(Required)
Last Name
(Required)
Email Address
(Required)
Phone Number
(Required)
Are you currently being treated by a physician for a specific condition?
(Required)
Yes
No
Yes No If so, please tell us about your treatment
(Required)
Have you recently been hospitalized or had a major operation?
(Required)
Yes
No
If so, please tell us about the hospitalization
(Required)
Have you ever had a serious head or neck injury?
(Required)
Yes
No
If so, please tell us about the head/neck injury
(Required)
Are you taking any medications, pills, or drugs?
(Required)
Yes
No
Please list all medications and dosage
(Required)
Are you on a special diet?
(Required)
Yes
No
Please tell us about your diet
(Required)
Do you use tobacco?
(Required)
Yes
No
Please tell us how often and what type of tobacco consumption
(Required)
Recreational drug and/or alcohol use, combined with local anesthesia may cause a life-threatening emergency.
(Required)
Have you ever been advised that you require antibiotics prior to a dental appointment?
(Required)
Yes
No
Please tell us about the antibiotics
(Required)
Do you take, or have you taken, PhenFen or Redux?
(Required)
Yes
No
If so, please tell us about your PhenFen/Redux usage
(Required)
Have you ever taken Fosomax, Boniva, Actonel or any other medications containing bisphosphonates?
(Required)
Yes
No
If so, please tell us about your bisphosphonate usage
(Required)
Have you recently used controlled substances?
(Required)
Yes
No
If so, please tell us which controlled substances and amount/frequency
(Required)
Have you recently consumed alcohol?
(Required)
Yes
No
Please tell how much alcohol and how recently
(Required)
Please answer if filling this form out on the day of your appointment Please tell how much alcohol and how recently
(Required)
Women (Please check all that apply)
Pregnant
Currently nursing
Trying to get pregnant
Taking oral contraceptives
None of the above
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic)
Aspirin
Acrylic
Erythromycin
Iodine
Latex
Local Anesthetics
Metal
Novocaine
Nitrous Oxide
Penicillin
Sulfa Drugs
Tetracycline
Valium
Xylocaine
None of the Above
Do you have, or have you ever had any of the following medical conditions? (Please select all that apply)
Anemia
Chemotherapy
Cold Sores/Fever Blisters
Cortisone Medication
Excessive Bleeding
Frequent Cough
Frequent Headaches
Hay Fever
Hemophilia
High Blood Pressure
Hives or Rash
Kidney Problems
Liver Disease
Parathyroid Disease
Recent Weight Loss
Rheumatism
Shingles
Spina Bifida
Stroke
Thyroid Disease
Venereal Disease
Arthritis or Gout
Blood Disease
Bruise Easily
Congenital Heart Problems
Diabetes
Drug/Alcohol Addiction
Emphysema
Frequent Urination
Heart Murmur
Heart Valve or Pacemaker
Herpes
Hypoglycemia
Lung Disease
Rheumatic Fever
Tuberculosis
Ulcers or GI Problems
Asthma
Chest Pains
Convulsions
Easily Winded
Excessive Thirst
Frequent Diarrhea
Genital Herpes
Heart Attack/Heart Failure
Hepatitis (B or C)
Low Blood Pressure
Irregular Heartbeat
Leukemia
Mitral Valve Prolapse
Radiation Treatments
Renal Disease
Scarlet Fever
Sickle Cell Disease
Stomach/Intestinal Disease
Swelling of Limbs
Tonsillitis
Yellow Jaundice
Artificial Joint
Blood Transfusion
Cancer
Currently Pregnant
Dizziness or Fainting
Eating Disorder
Epilepsy or Seizures
Glaucoma
Heart Trouble
Hepatitis (A)
HIV-AIDS-ARC
Jaw Joint Pain
Psychiatric Care
Sinus Problems
Tumor or Growth
X-ray/Chemotherapy
No to All
Do you have any condition or problem, not listed, which we should know about? Please explain
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.
By providing a mobile number, I agree that Newport Beach Dental Center may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.
CAPTCHA
Δ
Get in Touch
Name
(Required)
FIRST NAME*
LAST NAME*
Phone Number
(Required)
EMAIL*
(Required)
BRIEF MESSAGE
(Required)
By providing a mobile number, I agree that Newport Beach Dental Center may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.
Untitled
I consent to receive SMS text messages from Newport Beach Dental Center. Message and data rates may apply. Reply stop to opt out
CAPTCHA
Δ
1441 Avocado Ave, Ste 606 Newport Beach, CA 92660
Directions
(949) 760-9212
About
Services
Patients
Payment
Blogs
Contact
Appointment Request
X
RETURN
We Are Here For You
FIRST NAME*
(Required)
LAST NAME*
(Required)
Email *
BRIEF MESSAGE*
(Required)
CAPTCHA
Δ
About
Services
Patients
Payment
Blogs
Contact
Appointment Request
X
RETURN
FIRST NAME*
LAST NAME*
PHONE NUMBER*
EMAIL*
BRIEF MESSAGE
Submit
