The personal information provided below will be protected and keep private by our office. All information will be used and disclosed responsibly according to the Privacy Act standards set up and monitored by our office.
ALL INFORMATION IS CONFIDENTIAL
The following information is required by the dentist to assist in proper diagnosis and treatment
1. Have you ever had a serious illness requiring hospitalization or extensive medical care?
2. Are you presently under the care of a physician?
3. Have you had a medical examination in the last year?
4. Do you use any prescription or non-prescription drugs regularly?
5. Do you have any allergic conditions: e.g. hay fever, skin rash, food allergies, metal, latex?
6. Do any allergic reactions result in headaches, shortness of breath, chest constriction, nausea?
7. Have you been hospitalized in the last 5 years?
8. Have you ever experienced any unusual reaction to any of the following?
9. Have you been warned against taking any drug or medication?
10. Do you bruise easily or bleed abnormally?
11. Do you require pre-medication for dental treatment?
12. Have you ever had any organ implants or medical implants?
13. Have you ever fainted?
14. Do your ankles swell?
15. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?
16. Do you have frequent headaches?
17. Do you have A.I.D.S. or have you ever tested positive for H.I.V.?
19. Have you had any injury, surgery or x-ray therapy to your face OF jaws?
20. Do you have any disease, condition, or problem that you think the doctor should know about?
21. WOMEN ONLY
Are you pregnant or suspect you might be? If so, what month are you in?
Are you taking birth control pills?
Are you nursing?
Dr. Lloyd G. Pedvis Dentistry Professional Corporation