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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?

Other

Please list all current medications:

Do you have or have you experienced any of the following?

Abnormal Bleeding*

Yes

Drug Abuse*

Yes

Memory Loss*

Yes

Acid Reflux*

Yes

Emphysema*

Yes

Mitral Valve Prolapse*

Yes

Alcohol Abuse*

Yes

Epilepsy*

Yes

Occlusal Appliance*

Yes

Arthritis*

Yes

Glaucoma*

Yes

Pacemaker*

Yes

Artificial Joints*

Yes

Headaches*

Yes

Psychiatric Care*

Yes

Artificial Valves*

Yes

Heart Murmur*

Yes

Radiation Treatment*

Yes

Asthma*

Yes

Heart Surgery*

Yes

Rheumatic Fever*

Yes

Blood Transfusion*

Yes

Hepatitis*

Yes

Sinus Problems*

Yes

Cancer*

Yes

HIV+/AIDS*

Yes

Snoring/Sleep Apnea*

Yes

Chemotherapy*

Yes

High Blood Pressure*

Yes

Stroke*

Yes

Congenital Heart Defect*

Yes

Hearing Impaired*

Yes

Thyroid Problems*

Yes

Depression*

Yes

Kidney Problems*

Yes

Tuberculosis (TB)*

Yes

Diabetes*

Yes

Liver Disease*

Yes

Ulcers*

Yes

Anxiety*

Yes

High Cholesterol*

Yes

Vertigo*

Yes

Autism*

Yes

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

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*

RiverRock Dental in Shakopee, MN is a multi specialty dental clinic. Our dentists, Dr. Todd Christianson and Dr. Andrew Backes hold over a decade of collective clinical expertise to provide quality specialized dental care at affordable price. Each member of our team is dedicated to ensuring that our patients are well-informed and comfortable at all times. At RiverRock Dental, we will never begin a treatment or procedure until all of your questions have been answered and you feel relaxed and at ease. To give you the best possible services and results, we are committed to continual education and learning. Being member of various dental association’s helps us to stay abreast of the changes and recommendations for our profession.

Medical History Form

Medical History

Do you have or have you experienced any of the following?

Women :

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