Medical and Dental History Form NVD UPDATE
(MM/DD/YYYY)
14001 N 7th St, D108 Phoenix, Arizona 85022 (602) 866-8800
North Valley Dentistry
Medical History
Signature (Enter Full Name):
If so, where?
Signature will be recorded later.
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:
Y
Dental History
Pharmacy Phone Number:
N
N
Does 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 Information
Have you ever had dental/local anesthetic?
Y
Do 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 Cough
Reason
Radiation Treatment
Yes
Are you under a physician`s care at this time?
Slow Healing of Wounds
Fainting
No
COVID-19
Do you have any other allergies?
HIV/AIDS
Aspirin/Ibuprofen
Anesthetic
Y
N
Y
N
Are you allergic to any of the following?
Do you have any of the following medical conditions?
Penicillin
Sulfa
Codeine
Latex
N
Emergency 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 Form
Last Name:
Pregnancy
Diabetes
Psychiatric Treatment
Heart Murmur
Sinus Trouble
Cancer/Growth/Tumor
Asthma
Kidney Disease
Prolonged Bleeding
Liver Disease
N
Heart Condition
Stroke
High Blood Pressure
Ulcers/Stomach Issues
Joint Replacement/Prosthesis/Implant
Rheumatic Fever
Date: 4/19/2024
Y
Y
Dose 2
Have you been vaccinated for COVID Dose 1