Dr. Sukhminder Buttar

16600 West Valley Highway, Tukwila, Washington 98188

425-251-6044

Name:
Phone:
Email:

Medical History

Do you have a personal physician?
Physician's Name:
Phone#:
Date of last visit:
Your current physical health is:
Are you currently under the care of a physician?
Please explain:
Do you smoke or use tobacco in any other form?
Are you taking any prescription/over-the-counter drugs?
Please list each one:

For Women:

Are you taking birth control pills?
Are you pregnant?
Week#:
Are you nursing?

Have you ever had any of the following Diseases or medical problems

Anemia / Radiation Treatment
Artificial Bones / Joints
Artificial Valves
Asthma / Arthritis
Blood Transfusion
Cancer / Chemotherapy
Congenital Heart Defect
Diabetes / Tuberculosis (TB)
Difficulty Breathing
Drug / Alcohol Abuse
Emphysema / Glaucoma
Epilepsy/ Seizures/ Fainting Spells
Fever Blisters / Herpes
Heart Attack / Stroke
Heart Murmur
Heart Surgery / Pacemaker
Hemophilia/ Abnormal Bleeding
Hepatitis
High / Low Blood Pressure
HIV+ / AIDS
Hospitalized for any reason
Kidney Problems
Mitral Valve Prolapse
Psychiatric Problems
Rheumatic / Scarlet Fever
Severe / Frequent Headaches
Sinus Problems
Ulcers / Colitis
Venereal Disease
Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?

Aspirin
Codeine
Local Anesthetics
Erythromycin
Latex, Rubber
Penicillin
Tetracycline
Other
Please list any other drugs that you are allergic to:

Dental History

Previous/present dentist Name:
Phone#:
Location:
Last Cleaning Date
Do you now or have you ever experienced pain discomfort in your jaw joint (TMJITMD)?
Your current dental health is:
Do you like your smile?
How many times a week do you brush?
Floss?
Have you lost any teeth?
If yes, why?

Have you ever had any of the following?

Do your gums bleed while brushing or flossing?
Tooth sensitivity to heat or cold?
Tooth sensitivity to sweet or sour liquids/foods?
Pain in any of your teeth
Sores or lumps in or near your mouth
Head, neck or jaw injuries?
Any clicking, pain, or difficulty opening, closing or chewing in your jaw?
Frequent headaches?
Clenching or grinding your teeth?
Frequent biting of cheeks or lips?
Experienced a difficult extraction or prolonged bleeding following?
Orthodontic treatment
Additional Comments:

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

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Date

OFFICE USE ONLY

I have verbally reviewed the medical / dental information above with the parent / guardian & patient name herein

Reviewed with:
Date:
Dentist's Comments

Medical History Update

I have read my medical history dated and confirmed that it states past and present medical conditions.

Signature

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Date:

I have read my medical history dated and confirmed that it states past and present medical conditions.

Signature

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Date:

I have read my medical history dated and confirmed that it states past and present medical conditions.

Signature

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Date: