(MM/DD/YYYY)14001 N 7th St, D108 Phoenix, Arizona 85022 (602) 866-8800North Valley DentistryMedical HistorySignature (Enter Full Name):If so, where?
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Signature:Any part of your mouth sore to pressures or irritants (cold, sweets, etc.)?Any difficult extractions in the past?Do your gums bleed?Where was your x-ray taken?Prolonged bleeding following extractions in the past?Do you at the present time have any dental complaints?Do you chew on only one side of your mouth? If so, why?When was your last full mouth x-ray taken?Pharmacy Name:YDental HistoryPharmacy Phone Number:NNDoes any part of your mouth hurt when clenched?Have you experienced any growth or sore spots in your mouth?Any other medical conditions that are not listed above?Pharmacy InformationHave you ever had dental/local anesthetic?YDo you habitually clench your teeth during the night or day?Any reactions/allergic symptoms to Dental/Local anesthetic?Have you ever had instructions on the care of your gums and teeth?When was your last dental checkup?Night Sweats with Weight Loss and CoughReasonRadiation TreatmentYesAre you under a physician`s care at this time?Slow Healing of WoundsFaintingNoCOVID-19Do you have any other allergies?HIV/AIDSAspirin/IbuprofenAnestheticYNYNAre you allergic to any of the following?Do you have any of the following medical conditions?PenicillinSulfaCodeineLatexNEmergency Contact:List any medications you are taking or changes in medications:Relationship:Phone:City/State:Name of Medical Doctor:Birthdate:First Name:Medical and Dental History FormLast Name:PregnancyDiabetesPsychiatric TreatmentHeart MurmurSinus TroubleCancer/Growth/TumorAsthmaKidney DiseaseProlonged BleedingLiver DiseaseNHeart ConditionStrokeHigh Blood PressureUlcers/Stomach IssuesJoint Replacement/Prosthesis/ImplantRheumatic FeverDate: 3/25/2023YYDose 2Have you been vaccinated for COVID Dose 1