Medical and Dental History Patient Details

Medical and Dental History Medical History

  •  Yes
  •  No
  •  Good
  •  Fair
  •  Poor
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

CONDITIONS

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

If Female, Please Answer

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Chest pain (angina)
  •  Blood in stools
  •  Frequent vomiting
  •  Fainting spells
  •  Diarrhea or constipation
  •  Jaundice
  •  Recent significant weight loss
  •  Dry mouth
  •  Fever
  •  Difficulty urinating
  •  Excessive thirst
  •  Night sweats
  •  Ringing in ears
  •  Difficulty swallowing
  •  Persistent cough
  •  Swollen ankles
  •  Coughing up blood
  •  Dizziness
  •  Joint pain or stiffness
  •  Bleeding problems
  •  Blurred vision
  •  Shortness of breath
  •  Blood in urine
  •  Bruise easily
  •  Sinus problems
  •  NONE OF THE ABOVE
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Medical and Dental History Dental history

SELECT APPROPRIATE ANSWER (Leave blank if you do not understand the question)

  •  Checkup
  •  Pain
  •  Cleaning
  •  Other
  •  Less than 6 months ago
  •  More than 6 months but less than 1 year
  •  More than 1 year
  •  Do not remember
  •  1 time per day
  •  2 times per day
  •  More than 2 times per day
  •  Not every day
  •  Do Not brush my teeth
  •  1 time per day
  •  2 times per day
  •  More than 2 times per day
  •  Not every day
  •  Do Not floss my teeth
  •  Manual
  •  Powered
  •  Bad breath
  •  Bleeding gums
  •  Clicking or popping jaw
  •  Food collection between teeth
  •  Periodontal treatment
  •  Grinding teeth
  •  Loose teeth
  •  Sensitivity to COLD
  •  Sensitivity to HEAT
  •  Oral surgery
  •  Stain/discolored teeth
  •  Broken fillings
  •  Sensitivity to SWEETS
  •  Sensitivity to BITING
  •  TMJ Pain
  •  Wear Dentures/Partial
  •  Had Braces
  •  NONE OF THE ABOVE
  •  Recreational drugs
  •  Over-the-counter medicines
  •  Weight loss medications
  •  Tobacco in any form
  •  Alcohol
  •  Bisphosphonate (Fosamax)
  •  Antibiotics
  •  Supplements
  •  Aspirin
  •  NONE OF THE ABOVE

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to the commencement of dental treatment.

I authorize the dentist to contact my physician.

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I certify that I have read and understood this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist about any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

  •  I ACCEPT
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WADE AHWAL DDS MPH
8881 Fletcher PKWY STE 265
La Mesa CA 91942
T:  (619) 463-1113
F:  (619) 463-1249
email: admin@parkway-dental.com
www.parkway-dental.com

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