Cal Dental Group Pasadena

1213 N. Lake Ave, Suite 1 Pasadena, CA 91104

626-584-1800

MEDICAL HISTORY

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Name:
Phone:
Email:
Physician Name:
Physician Phone #:
Pharmacy
Pharmacy Phone #:
Sex
If Female please answer the following:
Are you taking Birth Control Pills?
Are you nursing?
Are you pregnant?
If Yes, # of weeks:
Please answer the following:
Do you smoke or use tobacco?
Height:
Weight:
For Office Use Only
BP:
Heart Rate:
Conditions
Abnormal Bleeding
Alcohol/ Drug Abuse
Anemia
Antibiotic Pre-Med
Arthritis
Artificial Heart Value
Artificial Joint
Prophylactic Aspirin
Asthma
Osteoporosis-Bisphosphonates?
Cancer- Chemotheraphy/ Radiation
Chicken Pox
Cosmetic Surgery
Diabetics
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells/ Seizures
Fever Blisters- Growth Or Sore Spots
Glaucoma
HIV+, AIDS
Heart Attack
Year
Heart Problems
Hemophilia
Hepatitis A, B Or C
High Blood Pressure
Hospitalizations
Year
Kidney Problems
Liver Disease
Pace Maker
Pshychiatric Problems
Serious Illness
Sickle Cell Disease
Slow Healing
Stroke
Surgery
Thyroid Problems
Tuberculosis
Venereal Disease
Appearance of your Teeth?
Are You Under A Lot Of Stress?
Dental Complaints
Dental Phobia
Frequent Head/ Neck Pain
Grind Or Clench Teeth
Jaw Pain/TMJ Dysfunction
Oral Surgery/ Braces / Periodontal Tx
Popping/ Locking Jaws
Tooth Loosening
Wish To Save Remaining Teeth?
Allergies
Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline
Other
Current Medications (Prescription and non-prescription):

Medication

Reason

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FOR OFFICE USE ONLY - NOTES

Patient or Parent Signature

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Date

Dentist’s Signature

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