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About
Dr. Travis Mattson
Dr. Timothy Obradovich
Dr. Haley Doose
Dr. Samuel Bander
Meet the Team
Office Tour
Patient Video Testimonials
Services
Preventive Dentistry
Gum Disease Treatments
Dental Cleanings & Exams
Dental Hygiene
Composite Tooth Fillings
Dental Sealants
Fluoride Treatment
Oral Cancer Screenings
Cosmetic Dentistry
Dental Bonding
Porcelain Dental Veneers
Inlays & Onlays
Zoom Teeth Whitening
Teeth Whitening
Restorative Dentistry
Dental Bridges
Composite Fillings
Dental Crowns
Dental Implants
All-On-Four
Dentures
Additional Dentistry
Athletic Mouth Guards
Children’s Dentistry
Dental Emergencies
Night Guards
Sedation Dentistry
Sleep Apnea Treatment
TMD & TMJ Therapy
Wisdom Teeth Removal
Holistic Dentistry
Endodontics
Root Canal Therapy
Apicoectomy
Oral Surgery
Tooth Extraction
Crown Lengthening
Gum Grafting
Bone Grafting
Orthodontics
Invisalign
Aligners
Retainers
ClearCorrect
New Patients
Dental History Form
Medical History Form
Resources
Pay Online
Dental Emergency FAQ
Dental Technology
Smile Gallery
Educational Videos
Dental Blog
Pay Online
Contact
Request an Appointment
Home
About
Dr. Travis Mattson
Dr. Timothy Obradovich
Dr. Haley Doose
Dr. Samuel Bander
Meet the Team
Office Tour
Patient Video Testimonials
Services
Preventive Dentistry
Gum Disease Treatments
Dental Cleanings & Exams
Dental Hygiene
Composite Tooth Fillings
Dental Sealants
Fluoride Treatment
Oral Cancer Screenings
Cosmetic Dentistry
Dental Bonding
Porcelain Dental Veneers
Inlays & Onlays
Zoom Teeth Whitening
Teeth Whitening
Restorative Dentistry
Dental Bridges
Composite Fillings
Dental Crowns
Dental Implants
All-On-Four
Dentures
Additional Dentistry
Athletic Mouth Guards
Children’s Dentistry
Dental Emergencies
Night Guards
Sedation Dentistry
Sleep Apnea Treatment
TMD & TMJ Therapy
Wisdom Teeth Removal
Holistic Dentistry
Endodontics
Root Canal Therapy
Apicoectomy
Oral Surgery
Tooth Extraction
Crown Lengthening
Gum Grafting
Bone Grafting
Orthodontics
Invisalign
Aligners
Retainers
ClearCorrect
New Patients
Dental History Form
Medical History Form
Resources
Pay Online
Dental Emergency FAQ
Dental Technology
Smile Gallery
Educational Videos
Dental Blog
Pay Online
Contact
Request an Appointment
New Patient Form
Fill Out Our Medical History Form Below
Patient Name
*
Nickname
Age
*
Name of Physician
*
Physician's Specialty
*
Most Recent Physical Examination
*
Physical Examination Purpose
*
Estimate of your general health?
*
Excellent
Good
Fair
Poor
DO YOU HAVE or HAVE YOU EVER HAD:
1. hospitalization for illness or injury
*
YES
NO
2. an allergic or bad reaction to any of the following:
*
NO ALLERGIES
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
chlorhexidine (CHX)
metals (nickel, gold, silver, etc)
latex
nuts
fruit
milk
red dye
other
2. Other Allergies
3. heart problems, or cardiac stent within the last six months
*
YES
NO
4. history of infective endocarditis
*
YES
NO
5. artificial heart valve, repaired heart defect (PFO)
*
YES
NO
6. pacemaker or implantable defibrillator
*
YES
NO
7. orthopedic or soft tissue implant (e.g joint replacement, breast implant)
*
YES
NO
8. heart murmur, rheumatic or scarlet fever
*
YES
NO
9. high or low blood pressure
*
YES
NO
10. a stroke (taking blood thinners)
*
YES
NO
11. anemia or other blood disorder
*
YES
NO
12. prolonged bleeding due to a slight cut (or INR > 3.5)
*
YES
NO
13. pneumonia, emphysema, shortness of breath, sarcoidosis
*
YES
NO
14. chronic ear infections, tuberculosis, measles, chicken pox
*
YES
NO
15. breathing problems (e.g. asthma, stuffy nose, sinus congestion)
*
YES
NO
16. sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)
*
YES
NO
17. kidney disease
*
YES
NO
18. liver disease or jaundice
*
YES
NO
19. vertigo (e.g. ”the room is spinning”)
*
YES
NO
20. thyroid, parathyroid disease, or calcium deficiency
*
YES
NO
21. hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)
*
YES
NO
22. high cholesterol or taking statin drugs
*
YES
NO
23. diabetes (HbA1c = )
*
YES
NO
24. stomach or duodenal ulcer
*
YES
NO
25. digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
*
YES
NO
26. osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)
*
YES
NO
27. arthritis or gout
*
YES
NO
28. autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)
*
YES
NO
29. glaucoma
*
YES
NO
30. contact lenses
*
YES
NO
31. head or neck injuries
*
YES
NO
32. epilepsy, convulsions (seizures)
*
YES
NO
33. neurologic disorders (ADD/ADHD, prion disease)
*
YES
NO
34. viral infections and cold sores
*
YES
NO
35. any lumps or swelling in the mouth
*
YES
NO
36. hives, skin rash, hay fever
*
YES
NO
37. STI/STD/HPV
*
YES
NO
38. hepatitis
*
YES
NO
38. hepatitis Type:
*
39. HIV/AIDS
*
YES
NO
40. tumor, abnormal growth
*
YES
NO
41. radiation therapy
*
YES
NO
42. chemotherapy, immunosuppressive medication
*
YES
NO
43. emotional difficulties
*
YES
NO
44. psychiatric treatment or antidepressant medication
*
YES
NO
45. concentration problems or ADD/ADHD diagnosis
*
YES
NO
46. alcohol/recreational drug use
*
YES
NO
ARE YOU:
47. presently being treated for any other illness
*
YES
NO
48. aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)
*
YES
NO
49. taking medication for weight management
*
YES
NO
50. taking dietary supplements
*
YES
NO
51. often exhausted or fatigued
*
YES
NO
52. experiencing frequent headaches or chronic pain
*
YES
NO
53. a smoker, smoked previously or other (smokeless tobacco, vaping, e-cigarettes, and cannabis)
*
YES
NO
54. considered a touchy/sensitive person
*
YES
NO
55. often unhappy or depressed
*
YES
NO
56. taking birth control pills
*
YES
NO
57. currently pregnant
*
YES
NO
58. diagnosed with a prostate disorder
*
YES
NO
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)
List all medications, supplements, and or vitamins taken within the last two years
Drug
Purpose
Drug
Purpose
Drug
Purpose
Drug
Purpose
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Patient's Signature
*
Patient's Signature
*
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Date
*
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