Michael S. Fife, DDS, DICOI, FMII, Inc.

1801 Professional Drive, Sacramento, California 95825

916-974-1160

MEDICAL & DENTAL HISTORY

Patient Name:
Phone:
E‐mail:
Are you currently under the care of a physician?
Physician’s Name:
If yes, please explain:
Are you taking any prescription or over the counter drugs?
If yes, please list each one:
Do you bleed excessively when injured?
For Women:
Are you pregnant?
Are you nursing?
Are you currently taking birth control?
Please Select either Yes or No for all conditions below that you have or have not had:
AIDS/HIV+
Arthritis
Asthma
Stroke
Vertigo
Tuberculosis
Heart Problem
*Pre-Med
Pacemaker
Liver Disease
Cancer
Diabetes
Hepatitis A/B/C
Epilepsy
High Blood Pressure
Sinus Problems
Siezures
Kidney Problems
Low Blood Pressure
Rheumatic Fever
Other
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
Erythromycin
Codeine
Metals (Jewelry)
Penicillin
Tetracycline
Latex Gloves
Ibuprofen
Sulfa
Dental Anesthetic
Acetaminophen
Other
Please list any other allergies:
What was your previous dentist’s name?
Date of last visit?
Have you ever had Periodontal corrections; for example: Gum surgery/ Root Planing/ Deep Cleaning
Have you ever had Orthodontic appliances/ Braces/ etc.?
Do your gums bleed after brushing or flossing?
Do you smoke or chew tobacco?
If yes, how much and/or often?
Have you ever taken medication for Osteoporosis?
If yes, what?
Have you had any type of implant placed or joint replacement in the last year
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 Craftsman Dental Care of any changes in the above information as soon as I am aware.

Patient's Signature:

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Date:

Guardian's Signature:

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Date: