Matthew S. Cowman DDS, Inc. 1300 Grand Ave. ste E, San Diego, CA 92109
Last NameLast Name is a required field
First NameFirst Name is a required field
Invalid Date of Birth. Format MM/dd/yyyy
Birthdate(MM/DD/YYYY)Birthdate is a required field
Home Phone
Do you have any of the following diseases or problems?
Tuberculosis
Persistent cough great than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis
If you answer yes to any of the 4 items above, please sign and call the office.
DENTAL INFORMATION - Please check your responses to the following questions
Do your gums bleed?
Are your teeth sensitive?
Does food or floss catch between your teeth?
Do you have dry mouth?
Have you had any gum treatments?
Have you ever had any orthodontic treatment?
Have you had any problems associated with previous dental treatment?
If yes, please explain
Do you have earaches or neck pain?
Do you grind your teeth?
Do you have discomfort in the jaw?
Do you have mouth sores or uclers?
Do you wear dentures or removable partials?
Have you ever had an injury to your head or mouth?
If yes, please explain
NEW PATIENTS ONLY
Date of last dental exam:
What is the reason for your dental visit today?
Date of last dental x-rays:
How do you feel about your smile?
Name of previous dentist
MEDICAL INFORMATION - Please check the appropriate box if you currently have or have had in the past, any of the conditions below
Are you now under the care of a physician?
Physician Name:
Address/City/St/Zip:
Phone Number:
Date of last physical exam:
Have you had a serious illness, operation, or been Hospitalized in the past 5 years?
If yes, please explain
Are you taking or have recently taken any prescription or over the counter medicines?
PLEASE LIST ALL
Enter Medication 1
Enter Medication 2
Enter Medication 3
Enter Medication 4
Enter Medication 5
Enter Medication 6
Do you wear contact lenses?
***Has a physician/previous dentist recommended that you take antibiotics prior to your dental treatments?
If yes, please explain
Joint Replacement. Have you had an orthopedic total joint(hip, knee, ankle, etc.) replacement?
Date:
Please explain:
Do you use controlled substances(drugs?)
Do you use tobacco products?
Do you use marijuanna?
Do you drink alcoholic beverages?
If yes, how much alcohol do you typically drink in a day?
Since 2001, were you treated or are presently scheduled to begin treatment with the intravenous bisphosphantes (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget's Disease, multiple myeloma or mestastic cancer?
Dr. Name/Phone:
Are you taking or schedule to begin taking either of the medications, alendronate(Fosomax) or risderonate (Actonel) for osteoporosis or Paget's disease?
Pregnancy
Number of weeks:
Taking birth controll pills or hormonal replacements?
Nursing?
ALLERGIES
Local Anesthetic
Aspirin
Penicillin or other antibiotics
If yes, please list below
Sedatives or sleeping pills
Sulfa Drugs
Codeine/other drugs
If yes, please list below
Metals
If yes, please list below
Latex Rubber
Iodine
Seasonal/Animals
Any other Allergies list below
(Except the conditions listed below, antibiotics for prophylaxis isn`t recommended.)
Artificial (prosthetic) heart valve
Damaged valves in transplanted heart
Congenital heart disease/defects
Please check your response to indicate if you have or have had in the past any of the following disease or problems
Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur
Low blood pressure
High blood pressure
Mitral valve prolapse
Pacemaker
Rheumatic fever/heart disease
Abnormal bleeding
Anemia
Blood transfusion
*if yes, date:
Hemophilia
AIDS/HIV infection
Arthritis
Autoimmune disease
Asthma
Bronchitis
COPD
Sinus trouble
Cancer/Type
If yes, please explain:
Chemotherapy
Radiation
Chest pain upon exertion
Chronic pain
Diabetes Type 1 or 2
Eating disorder
Gastrointestinal disease
GE reflux/persistent heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Fainting spells
Epilepsy
Neurological disorders
*specify
Recurrent Infections
Type of Infections
Kidney problems
Osteoporosis
Persistent swollen glands
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Hepatitis, jaundice or liver disease
Rheumatoid arthritis
Systemic lupus erythematosus
Any other medical conditions not listed
EMERGENCY CONTACT:
EMERGENCY CONTACT PHONE NUMBER:
I certify that I have read and understand the above and the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set for above have been answered and to my satisfaction. I will not hold any dentist or any member of his staff responsible for any action they take or do not take because of errors or admissions that I may have made in the completion of this form. I authorize the dental staff to perform the necessary services I may need. I assign the Doctor ALL insurance benefits. I understand that I am responsible for ALL payments of services, any deductible, and co-payment that my insurance does not cover for any reason AS WELL AS responsible for the total amount due at the time the services are completed unless discussed prior to the appointment.
If you are completing this form for another person(First and last name)
Relationship:
Date(MM/DD/YYYY):