Asmath Noor, DDS, MDS

Norwalk Village Dental Center- 11274 E, Firestone Blvd, Norwalk, CA 90650

562-863-8600

Health Questionnaire

These questions are for your benefit and assure that treatment will take into consideration your past and present health status. Some questions may seem unrelated to your dental condition, but they are all associated with proper oral health care. Please answer each question. Check the appropriate box and/or select Yes or No where applicable.

Patient Name:
E-mail
Cell Phone

MEDICAL HISTORY

Are you in good health?
Date of last physical examination
Are you now under the care of a physician?
If so, what is the condition being treated?
Have you ever had any serious illness or operation?
If so, what illness or operation?
Have you ever been hospitalized?
If so, what was the problem?
Are you taking any
If so, what?
What dosage?
Are you using any recreational drugs (marijuana, cocaine, etc.)?
If so, what?
Have you ever been premedicated with antibiotics for your dental treatment?
Are you sensitive or allergic to any drugs or materials?
If Other, what drugs?

Do you have or have you had any of the following: (Please select 'Y' for Yes or 'N' for No - answer all conditions):

Respiratory Disease
Anemia
Excessive Bleeding
Heart Failure
Radiation Treatment of any kind
Chemotherapy
Ulcers
Stomach Ulcers
Hemophilia
Emphysema
Psychiatric Treatment
Fainting Spells
Thyroid Disease
Chicken Pox
Difficulty Swallowing
Tuberculosis (f.B.)
Head Injuries
Herpes
Joint Replacement
Glaucoma
Venereal Disease (Syphilis, Gonorrhea)
Rheumatism
Hepatitis or Jaundice
Congenital Heart Lesions
Implant (s)
Liver Disease
Asthma
Artificial Prosthesis
Heart Ailments
Seizures
Cortisone Medicine
Cerebral Palsy
Drug Addiction
Blood Disease
Blood Transfusion
High Blood Pressure
Sinus Trouble
HIV Related Complex
Angina Pectoris
Arthritis
Pain in Jaw Joints
Sickle Cell Disease
Heart Attack
Hay Fever
Allergies to Metals
Bruise Easily
Rheumatic Fever
Mental Disorder
X-Ray or Cobalt Treatment
Kidney Disease
Stroke
Nervous Disorders
Tonsillitis
Tumors or Growths
Heart Murmur
TMJ
Headaches
Mitral Valve Prolapse
Scarlet Fever
Cancer
Diabetes
Allergies or Hives
Epilepsy or Seizures
Cold Sores
Acquired Immune Deficiency Syndrome(AIDS)
Other
Do you have any disease, condition or problem not listed that you think we should know about?
If so, what?
Do you wear a cardiac pacemaker, or have you had heart surgery?
Do you smoke?
If yes, how much?
Have you ever taken the drugs
Women
Are you pregnant?
If so how many months?
Do you have any problems associated with your menstrual period?
Do you take any birth control medication or hormones?
DENTAL HISTORY
Have you ever had a local anesthetic (Novocaine, etc.)?
Have you ever had any unfavorable reaction from a local anesthetic?
Have you had any serious trouble associated with any previous dental treatment?
If so, explain?
How long since your last full mouth X-Rays?
Weeks
Months
Years
How long since your last dental treatment?
Weeks
Months
Years
Does dental treatment make you nervous
Would you desire to be pre-sedated?

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or if my medications change, I will, without fail, inform the doctor at my next appointment.

A

Date
Reviewed by
Lic#
Date

B UPDATE - Since your last visit A

Have you seen a medical doctor?
Have you had a change in your medication?
Have you had a change in your medical condition or had surgery?
Please note changes in health since last visit. If no changes, please write "None"

Signature:

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Date:

C UPDATE - Since your last visit

Have you seen a medical doctor?
Have you had a change in your medication?
Have you had a change in your medical condition or had surgery?
Please note changes in health since last visit. If no changes, please write "None"

Signature:

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Date:
A              B              C             
Reviewed By
Date
B.P.
Pulse
Temp

HEALTH QUESTIONNAIRE MUST BE CONTINUALLY UPDATED!

CONSENT FOR TREATMENT

I hereby grant authority to the dentist(s) in charge of the care of the patient whose name appears on this Health History form, to administer such anesthetics, analgesics, sedatives, nitrous oxide sedation and intravenous sedation; and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this patient. I have been informed of all possible complications of the procedures, anesthetics and/or drugs.

All services are rendered and accepted under the terms and conditions printed: Authorization must be signed by the patient, or by the nearest relative in the case of a minor or when the patient is physically or mentally incompetent

Patient's Signature:

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Date:

Doctor's Signature:

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Date: