Drslievanosnyder.com

Drs. Lievano, Snyder & Lopez
MEDICAL HISTORY
Patient Name: _________________________________ ●Are you under a physician’s care now? No If Yes, please explain ____________________________________________ ●Physician’s Name: ______________________________ Date of last visit: _____________ ●Have you ever been hospitalized / had a major operation? No If Yes, explain ____________________________________ ●Have you ever had a serious head or neck injury? No If Yes, explain ____________________________________ ●Are you taking any medications, pills, or drugs? No If Yes, explain ____________________________________ ●Do you take or have taken, Phen-Fen or Redux? No If Yes, when? ____________________________________ No If Yes, explain ____________________________________ ●Have you had any metal rods, pins or implants? No If Yes, explain/when? ______________________________ ●Do you require antibiotics before dental treatment? No If Yes, explain ____________________________________ ●Do you use tobacco in any form? No Yes ●Do you use controlled substances? No Yes ● Pregnant/Trying to get pregnant? No Yes, Due Date: ___________ ●Do you have, or have you had, any of the following? ●Have you had any serious illness not listed above? No If Yes, Please explain:______________________________________
●Are you allergic to any of the following? Aspirin Penicillin Acrylic Latex Metal Local Anesthetics
Other___________________________
●IMPORTANT: Have you ever been treated Osteoporosis, Osteopenia, Cancer and given one of the following
medications? No If Yes, please check: Actonel Fosamax Boniva Zometa Skeud Didronel Bonefos
Ostac Other___________________
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect
information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in
medical status.
If different than Patient, please print name of Parent or Guardian ________________________________________
Signature ____________________________________
Date______________
Drs. Lievano, Snyder & Lopez
DENTAL HISTORY
Patient Name: _________________________________ ●Who is your previous dentist?__________________________ ●Reason for changing?_________________________________ ●When was your last dental visit? _______________ ● What was done at your last visit?________________________________ ●What is the main reason for your first visit with us? _____________________________________________________________ Once a year Twice a Year Only when I have a problem Other _______________________________ ●Your current dental health is Good Fair Poor ●Have you ever had gum treatment? No Yes ●Are you currently in any type of dental pain or sensitivity? No If Yes, please explain _______________________________ ●You floss ____ times a week, and you brush ____ times a day. ●Are you nervous about coming to the dentist? No Yes ●Are you aware of an uncomfortable bite? No Yes ●Do you hear a “clicking” sound when you open/close your mouth? No Yes ●Do you grind or clench your teeth? No Yes ●Does food catch between your teeth? No Yes ●Do you have any dental implants? No Yes ●Do you wear any (partials/full) dentures? No Yes ●Do you have any crowns or bridges? No Yes ●Are you unhappy with the appearance of your teeth? No Yes ●Would you like straighter teeth? No Yes ●What else do you consider important for us to know? ____________________________________________________________
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect
information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in
medical status.
If different than Patient, please print name of Parent or Guardian ________________________________________
Signature ____________________________________
Date______________

Source: http://drslievanosnyder.com/Portals/0/Patient_Medical_Form.pdf