Medical History and Consent

    Medical History and Consent

    Although dental personnel treat the area in and around your mouth, your mouth is a part of your entire body. Health conditions or problem that you may have or had, or medications that you may be taking could have an important Interrelationship with the treatment you will receive. Thank you for answering the following questions.



    GERD: YesNo


    Acrylics: YesNo

    Soft or Special Diet: YesNo

    Alzheimer’s Disease: YesNo

    Anaphylaxis: YesNo

    Ulcers: YesNo

    Diziness: YesNo

    Lalex: YesNo


    Fainting: YesNo

    Local Areshthetics: YesNo

    Frequent Urination: YesNo

    Memory Loss: YesNo

    Penicillin: YesNo

    Kidney Disease: YesNo

    Multiple Sclerosis: YesNo

    Metal: YesNo


    Muscle Weakness: YesNo

    Sulpha: YesNo

    Current Weight:

    Seizures: YesNo

    Other: YesNo


    Stroke: YesNo

    List other known allergies:

    Cancer: YesNo

    Tingling/ Numbness: YesNo


    Fatigue/ Tired: YesNo

    Trigeminal Neuralgia: YesNo


    General Weakness: YesNo

    Tremor: YesNo


    Headaches: YesNo



    HIV/AIDS: YesNo

    ADD/ADHD: YesNo


    Knee/hip Replacement: YesNo

    Anxiety: YesNo

    Artificial Heart Valve: YesNo

    Liver Problem: YesNo

    Chemical Dependency: YesNo

    Coronary Artery Disease: YesNo

    Recent Trauma or Injury: YesNo

    Depression: YesNo

    Chest Pain or Angina: YesNo

    Rheumatic Fever: YesNo

    Eating Disorder: YesNo

    Congestive Heart Failure: YesNo

    Radiation Treatment: YesNo

    Excessive Stress: YesNo

    Heart AttackYesNo:

    Weight Change: YesNo

    Memory Problems: YesNo

    Heart Murmur: YesNo



    High Blood Pressure: YesNo

    Bleeding Problems: YesNo

    Asthma: YesNo

    High Cholesterol: YesNo

    Hepatitis: YesNo

    Bronchitis: YesNo

    Irregular Heart Beat: YesNo


    Breathing Problems: YesNo

    Low Blood Pressure: YesNo

    Bleeding gums: YesNo

    Chest Pressure: YesNo

    Mitral Valve Prolapse: YesNo

    Dry Mouth: YesNo

    Congestion: YesNo

    Pacemaker: YesNo

    Jaw Problems (TMJ)? YesNo

    Dyspnea (shortness of breath): YesNo

    Tachycardia: YesNo

         Clicking? YesNo


         Pain? YesNo

    Emphysema: YesNo

    Diabetes: YesNo

         Difficulty Swallowing? YesNo

    Orthopnea: YesNo

    Goul: YesNo

         Difficulty chewing? YesNo

    Pneumonia: YesNo

    Hormonal Charge: YesNo

    Orthodontics/ Invisalign? YesNo

    Pulmonary Embolism: YesNo

    Thyroid Problem: YesNo

    Periodonial Disease: YesNo

    Tuberculosis: YesNo

    Eyes, Ears, Nose, and Throat

    Teeth Cleaning: YesNo


    Change in Hearing: YesNo

    Teeth Grinding: YesNo

    Daytime Sleepiness: YesNo

    Change in Vision: YesNo

    Tooth Pain: YesNo

    Morning Headache: YesNo

    Dysphagia: YesNo

    Wisdom teeth extraction: YesNo

    Obstructive Sleep Apnea: YesNo

    Ear Pain: YesNo

    Do you wear removable teeth: YesNo

    Do you us a CPAP? How often? YesNo

    Glaucoma: YesNo

    Do you take or need antibiotics before dental procedures? YesNo

    Has anyone told you that you snore? YesNo

    Hay Fever: YesNo


    Social Health

    Nasal Obstruction: YesNo

    Back Pain: YesNo

    Do you smoke? YesNo, Packs a day?

    Nose Bleeding: YesNo

    Fibromyalgia: YesNo

    Do you use smokeless tobacco? YesNo

    Sinus Problems: YesNo

    Joint Pain: YesNo

    Do you consume alcoholic beverages? YesNo, Drinks per day/ week/ Month:

    Tonsilleclomy : YesNo

    Do you recreational drugs? YesNo

    Tinnitu  (Ringing): YesNo


    Acid Reflux: YesNo


    Skyline Family Dentistry

    Gabriel Overholtzer D.D.S


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    Monday: 8am – 5pm
    Tuesday: 8am – 5pm
    Wednesday: 8am – 5pm
    Thursday: 8 am – 5pm
    Friday: Closed
    Saturday: Closed
    Sunday: Closed

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