952.445.5556
403 East First Avenue, Shakopee, MN 55379
riverrockdds@gmail.com
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General Dentist
Family Dentist
Dentist For Kids
Preventive Care
Cosmetic Dentist
Dental Crowns
Dental Implants
Teeth Whitening
Restorations and Fillings
Orthodontics
Root Canal Therapy
Dentures
Tooth Extractions
Botox
Gum Treatment
Promotions
Financial Info
Dental Plans
Our Team
Dental Staff
Our Dentists
BLOG
CONTACT
Payment
Patient Forms
About
Reviews
Services
General Dentist
Family Dentist
Dentist For Kids
Preventive Care
Cosmetic Dentist
Dental Crowns
Dental Implants
Teeth Whitening
Restorations and Fillings
Orthodontics
Root Canal Therapy
Dentures
Tooth Extractions
Botox
Gum Treatment
Promotions
Financial Info
Dental Plans
Our Team
Dental Staff
Our Dentists
BLOG
CONTACT
Menu
Patient Forms
About
Reviews
Services
General Dentist
Family Dentist
Dentist For Kids
Preventive Care
Cosmetic Dentist
Dental Crowns
Dental Implants
Teeth Whitening
Restorations and Fillings
Orthodontics
Root Canal Therapy
Dentures
Tooth Extractions
Botox
Gum Treatment
Promotions
Financial Info
Dental Plans
Our Team
Dental Staff
Our Dentists
BLOG
CONTACT
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Medical History Form
Medical History Form
Medical History
"
*
" indicates required fields
First Name
*
Last Name
*
Phone
*
Email
*
Current physical health is :
*
Good
Fair
Poor
Explain
Physician Name
Clinic Name
Are you allergic to any of the following?
Amoxicillin
Erythromycin
Penicillin
Aspirin
Jewelry
Sulfa Drugs
Codeine
Latex
Dental Anesthetics
Other
Other
Please list all current medications:
Do you have or have you experienced any of the following?
Abnormal Bleeding
*
Yes
No
Drug Abuse
*
Yes
No
Memory Loss
*
Yes
No
Acid Reflux
*
Yes
No
Emphysema
*
Yes
No
Mitral Valve Prolapse
*
Yes
No
Alcohol Abuse
*
Yes
No
Epilepsy
*
Yes
No
Occlusal Appliance
*
Yes
No
Arthritis
*
Yes
No
Glaucoma
*
Yes
No
Pacemaker
*
Yes
No
Artificial Joints
*
Yes
No
Headaches
*
Yes
No
Psychiatric Care
*
Yes
No
Artificial Valves
*
Yes
No
Heart Murmur
*
Yes
No
Radiation Treatment
*
Yes
No
Asthma
*
Yes
No
Heart Surgery
*
Yes
No
Rheumatic Fever
*
Yes
No
Blood Transfusion
*
Yes
No
Hepatitis
*
Yes
No
Sinus Problems
*
Yes
No
Cancer
*
Yes
No
HIV+/AIDS
*
Yes
No
Snoring/Sleep Apnea
*
Yes
No
Chemotherapy
*
Yes
No
High Blood Pressure
*
Yes
No
Stroke
*
Yes
No
Congenital Heart Defect
*
Yes
No
Hearing Impaired
*
Yes
No
Thyroid Problems
*
Yes
No
Depression
*
Yes
No
Kidney Problems
*
Yes
No
Tuberculosis (TB)
*
Yes
No
Diabetes
*
Yes
No
Liver Disease
*
Yes
No
Ulcers
*
Yes
No
Anxiety
*
Yes
No
High Cholesterol
*
Yes
No
Vertigo
*
Yes
No
Autism
*
Yes
No
If you answered YES to any of the questions above, please explain:
Tobacco Use?
What form of tobacco and how frequent?
Has any doctor recommended pre-medication with antibiotics before dental appointments for any reason? Explain:
List any serious medical condition(s) you have experienced
Women :
Are you pregnant now?
How many months?
Are you happy with the appearance of your smile?
*
Yes
No
Explain
Any complications following dental treatment?
History of “deep cleaning” Scaling and Root Planning or Periodontal Surgery?
Anything else you would like us to know?
Consent
*
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.
*
Date
*
MM slash DD slash YYYY