Medical History

29 Palms Dental Group An Nguyen DDS MS Corporation

Medical history

Although dental personnel primarily treat the area in and around your mouth,Your mouth is a part of tour entire body. Health problems that you may have, or medication that you may be taking , could have an important internal relationship with the dentistry you will receive.

Thank you for answering the following questions:

    Are you under a physicians care now? (required)

    YesNo

    If Yes

    Have you ever been hospitalized? (required)

    YesNo

    If Yes

    Have you ever had a serious head or neck injury? (required)

    YesNo

    If Yes

    Are you taking any medications? (required)

    YesNo

    If Yes

    Do you take Phen-Fen or Redux? (required)

    YesNo

    If Yes

    Have you ever taken Fosamax, Boniva or Actonel? (required)

    YesNo

    If Yes

    Are you on a special diet? (required)

    YesNo

    If Yes

    Do you use tobacco? (required)

    YesNo

    If Yes

    Do you use a controlled substances? (required)

    YesNo

    If Yes

    Women Are you...

    Pregnant or about to get Pregnant?Nursing?Taking oral contraceptives?

    Are you allergic to any of the following? (required)

    AsprinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsOtherNone

    Other

    Do you have or have you had any of the following?

    AIDS/HIV Positive (required)

    YesNo

    Alzheimer's Disease (required)

    YesNo

    Anaphylaxis (required)

    YesNo

    Anemia (required)

    YesNo

    Angina (required)

    YesNo

    Arthritis/Gout (required)

    YesNo

    Artificial Joint (required)

    YesNo

    Asthma (required)

    YesNo

    Blood Disease (required)

    YesNo

    Blood Transfusion (required)

    YesNo

    Breathing Problems (required)

    YesNo

    Bruise Easily (required)

    YesNo

    Cancer (required)

    YesNo

    Chemotherapy (required)

    YesNo

    Chest Pains (required)

    YesNo

    Cold Sores (required)

    YesNo

    Heart Disorder (required)

    YesNo

    Convulsions (required)

    YesNo

    Yellow Jundice (required)

    YesNo

    Cortisone Medicine (required)

    YesNo

    Diabetes (required)

    YesNo

    Drug Addiction (required)

    YesNo

    Easily Winded (required)

    YesNo

    Emphysema (required)

    YesNo

    Epilepsy or Seizures (required)

    YesNo

    Excessive Thirst (required)

    YesNo

    Fainting/Dizzyness (required)

    YesNo

    Frequent Cough (required)

    YesNo

    Frequent Diarrhea (required)

    YesNo

    Frequent Headaches (required)

    YesNo

    Genital Herpes (required)

    YesNo

    Glaucoma (required)

    YesNo

    Hay Fever (required)

    YesNo

    Heart Failure (required)

    YesNo

    Heart Murmur (required)

    YesNo

    Pacemaker (required)

    YesNo

    Heart Disease (required)

    YesNo

    Hemophilia (required)

    YesNo

    Hepatitis A (required)

    YesNo

    Hepatitis B or C (required)

    YesNo

    Herpes (required)

    YesNo

    High Blood Pressure (required)

    YesNo

    High Cholesterol (required)

    YesNo

    Hypoglycemia (required)

    YesNo

    Irregular Heartbeat (required)

    YesNo

    Kidney Problems (required)

    YesNo

    Leukemia (required)

    YesNo

    Liver Disease (required)

    YesNo

    Low Blood Pressure (required)

    YesNo

    Lung Disease (required)

    YesNo

    Mitral Valve Prolaspse (required)

    YesNo

    Osteoporosis (required)

    YesNo

    Pain in Jaw Joints (required)

    YesNo

    Parathyroid Disease (required)

    YesNo

    Psychiatric Care (required)

    YesNo

    Radiation Treatments (required)

    YesNo

    Recent Weight Loss (required)

    YesNo

    Renal Dialysis (required)

    YesNo

    Rheumatic Fever (required)

    YesNo

    Rheumatism (required)

    YesNo

    Scarlet Fever (required)

    YesNo

    Sickle Cell Disease (required)

    YesNo

    Sinus Trouble (required)

    YesNo

    Spina Bifida (required)

    YesNo

    Intestinal Disease (required)

    YesNo

    Stroke (required)

    YesNo

    Swelling of Limbs (required)

    YesNo

    Thyroid Disease (required)

    YesNo

    Tonsillitis (required)

    YesNo

    Tuberculosis (required)

    YesNo

    Tumors Growths (required)

    YesNo

    Ulcers (required)

    YesNo

    Venereal Disease (required)

    YesNo

    Have you ever had any serious illness not listed? (required)

    YesNo

    If Yes

    Patient

    date

    An V Nguyen DDs MS

    date