PRESERVE PARKWAY DENTAL MEDICAL/DENTAL HISTORY

Name: ______Preferred Name: ______DOB:______

Gender: (M/F) Family status: (Married/ Single/Child) Do you have dental insurance? ____ (if so,please present your card)

EMAIL:______Best way to reach you via phone? Cell/ home/ work.

Phone: (Home)______(Cell):______(Work):______(ext)______

Address:______City:______State:_____ Zip:______

Occupation:______Employer:______Student(where?):______

Emergency Contact: ______Phone:______Relationship:______Medical History: Primary Care Physician’s Name/ location/ Phone #:______When was your last medical physical? ______WOMEN: Are you pregnant? ______Due date:______

Please CIRCLE if you have any of the following conditions:

Acid reflux AsthmaDiabetes High Blood Pressure Sinus Problems

ADD/ ADHD Autism Epilepsy HIV+ Stoke

AFib Chemical DependencyHigh CholesterolHepatitis Stents placed

Anemia COPD Heart Attack Kidney Disease Thyroid issues

Arthritis Dementia/AlzheimersHeart DiseaseLiver Disease Vertigo

Anxiety Depression Heart Failure OTHER:______

Cancer? ______Type of Treatment(circle): Chemo/Radiation/Surgery/none. Date:______

Any of the following: (circle)Joint replacement / Heart valve replacement/ Heart surgery? Date:______

Do you take antibiotic premedication prior to dental visits (list antibiotic/dose)?______

Any other Surgeries in the past two years?______

Please list all medications you are taking or provide medication list (including vitamins, aspirin etc): None?______

______Please list any medications you are ALLERGIC to:______Please list any other allergies: ______

Dental History Do you have of the following?(circle any that apply):

TMJ/TMD Sleep Apnea Snoring Hard Night Guard Cpap Snore Guard Clench/Grind habit

Do you/have you used tobacco products? (pleaselist type) ______Do you /have taken Osteoporosis Medications? (please list name and date last taken)______

Do you experience dry mouth?______If so, have tried anything to help it?______

Signature of Patient:______Date:______

(If minor)Parent/Guardian: ______Date:______

DDS Signature: ______Date: ______Summary:______

**** New Patients, See Reverse Side ****

Preserve Parkway Dental New Patient Questionnaire

How did you hear about our office?______Previous Dentist:______

How long has it been since you have seen a Dentist? ______Concerns you have for the Dentist today? ______

When was your Last Hygiene appointment?______

Have you or do you have had any of the following? (pleasecircle)

Gingivitis Gum Disease Halitosis Bleeding gums Painful gums Gum recession Grafting Scale/Root plane Gum surgery Oral cancer Biopsies Tongue issues Lichen Planus Other?______

Concerns for the Hygienist today?______

Have your previous dental experiences been positive?______

Is there anything else you would like us to know about your dental history?______

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