Lilliana Stojic DDS, MAGD

1801 Professional Drive, Sacramento, California 95825

916-487-5147

MEDICAL & DENTAL HISTORY

Patient Name:

Patient Name:

Phone:

Phone:

E‐mail:

E‐mail:

Are you currently under the care of a physician?

Are you currently under the care of a physician?

Yes No

Physician’s Name:

Physician’s Name:

If yes, please explain:

If yes, please explain:

Are you taking any prescription or over the counter drugs?

Are you taking any prescription or over the counter drugs?

Yes No

If yes, please list each one:

If yes, please list each one:

Do you bleed excessively when injured?

Do you bleed excessively when injured?

Yes No

For Women:

Are you pregnant?

Are you pregnant?

Yes No

Are you nursing?

Are you nursing?

Yes No

Are you currently taking birth control?

Are you currently taking birth control?

Yes No

Please Select either Yes or No for all conditions below that you have or have not had:

AIDS/HIV+

AIDS/HIV+

Yes No

Arthritis

Arthritis

Yes No

Asthma

Asthma

Yes No

Stroke

Stroke

Yes No

Vertigo

Vertigo

Yes No

Tuberculosis

Tuberculosis

Yes No

Heart Problem

Heart Problem

Yes No

*Pre-Med

*Pre-Med

Yes No

Pacemaker

Pacemaker

Yes No

Liver Disease

Liver Disease

Yes No

Cancer

Cancer

Yes No

Diabetes

Diabetes

Yes No

Hepatitis A/B/C

Hepatitis A/B/C

Yes No

Epilepsy

Epilepsy

Yes No

High Blood Pressure

High Blood Pressure

Yes No

Sinus Problems

Sinus Problems

Yes No

Siezures

Siezures

Yes No

Kidney Problems

Kidney Problems

Yes No

Low Blood Pressure

Low Blood Pressure

Yes No

Rheumatic Fever

Rheumatic Fever

Yes No

Other

Other

Yes No

If you Select YES to Heart Problem or Other, please explain:

If you Select YES to Heart Problem or Other, please explain:

Please Select either Yes or No for all of the items listed below that you may or may not be allergic to:

Aspirin

Aspirin

Yes No

Erythromycin

Erythromycin

Yes No

Codeine

Codeine

Yes No

Metals (Jewelry)

Metals (Jewelry)

Yes No

Penicillin

Penicillin

Yes No

Tetracycline

Tetracycline

Yes No

Latex Gloves

Latex Gloves

Yes No

Ibuprofen

Ibuprofen

Yes No

Sulfa

Sulfa

Yes No

Dental Anesthetic

Dental Anesthetic

Yes No

Acetaminophen

Acetaminophen

Yes No

Other

Other

Yes No

Please list any other allergies:

Please list any other allergies:

What was your previous dentist’s name?

What was your previous dentist’s name?

Date of last visit?

Date of last visit?

Have you ever had Periodontal corrections; for example: Gum surgery/ Root Planing/ Deep Cleaning

Have you ever had Periodontal corrections; for example: Gum surgery/ Root Planing/ Deep Cleaning

Yes No

Have you ever had Orthodontic appliances/ Braces/ etc.?

Have you ever had Orthodontic appliances/ Braces/ etc.?

Yes No

Do your gums bleed after brushing or flossing?

Do your gums bleed after brushing or flossing?

Yes No

Do you smoke or chew tobacco?

Do you smoke or chew tobacco?

Yes No

If yes, how much and/or often?

If yes, how much and/or often?

Have you ever taken medication for Osteoporosis?

Have you ever taken medication for Osteoporosis?

Yes No

If yes, what?

If yes, what?

Have you had any type of implant placed or joint replacement in the last year

Have you had any type of implant placed or joint replacement in the last year

Yes No

If yes, what?

If yes, what?

TREATMENT CONSENT

I understand that regardless of my dental insurance status, I am ultimately responsible for the balance of my account for any professional services received. I certify the information that I have provided on this form is true. I will notify Global Smiles of any changes in the above information as soon as I am aware.

Patient's Signature:

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Date:

Date:

Guardian's Signature:

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