• ATTILA FRANK TALABER, D.M.D.
    • AFFILIATE PROFESSOR U. OF W.
  • MEDICAL HISTORY FORM
    * Note: All Responses in BLUE are required!
  • NAME:
  • BIRTH DATE:
  • DATE:
  • FOR THE FOLLOWING QUESTIONS, SELECT "YES", "NO", OR A SPECIFIC ITEM. YOUR ANSWERS ARE CONFIDENTIAL.
  • WHO IS YOUR PRIMARY MEDICAL PHYSICIAN?
  • WHEN WAS YOUR LAST PHYSICAL EXAM?
  • IN THE PAST 5 YEARS, HAVE YOU HAD ANY SERIOUS ILLNESS, OPERATION, OR BEEN HOSPITALIZED?
  • DESCRIBE:
  • LIST ALL PRESCRIPTION DRUGS, NON-PRESCRIPTION DRUGS OR VITAMINS YOU CURRENTLY TAKE:
    • ARE YOU ALLERGIC TO:
    • ASPIRIN/ACETAMINOPHEN/IBUPROFEN
    • Yes No
    • CODEINE, DEMEROL, OTHER NARCOTICS
    • Yes No
    • BARBITUATES, SEDATIVES OR SLEEEPING PILLS
    • Yes No
    • PENICILLIN, ERYTHROMYCIN, TETRACYCLINE, OTHER ANTIBIOTICS
    • Yes No
    • SULFA DRUGS
    • Yes No
    • LATEX
    • Yes No
    • METALS OF ANY KIND
    • Yes No
    • LOCAL ANESTHETIC
    • Yes No
    • OTHER ALLERGIES (LIST):
    • Yes No
  • PLEASE SELECT "YES" OR "NO" TO INDICATE IF YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING:
      • HEART CONDITIONS:
      • ANGINA/CHEST PAIN (UPON EXERTION)
      • Yes No
      • ARTIFICIAL VALVE(S)
      • Yes No
      • HEART VALVE PROBLEMS
      • Yes No
      • HEART ATTACK/DISEASE/SURGERY
      • Yes No
      • HEART MURMUR
      • Yes No
      • HIGH/LOW BLOOD PRESSURE
      • Yes No
      • PACEMAKER
      • Yes No
      • RHEUMATIC FEVER
      • Yes No
      • INFECTIVE (BACTERIAL) ENDOCARDITIS
      • Yes No
      • LIVER PROBLEMS:
      • LIVER DISEASE
      • Yes No
      • HEPATITIS
      • A B C D E
      • Yes No
      • ONCOLOGIC PROBLEMS/TREATMENT:
      • CANCER (TYPE):
      • Yes No
      • CHEMOTHERAPY
      • Yes No
      • RADIATION THERAPY
      • Yes No
      • THYROID/PANCREAS/KIDNEY PROBLEMS:
      • HYPERTHYROIDISM
      • Yes No
      • HYPOTHYROIDISM
      • Yes No
      • DIABETES TYPE I OR II
      • Yes No
      • SLOW HEALING
      • Yes No
      • KIDNEY DISEASE
      • Yes No
      • BACTERIAL AND VIRAL INFECTIONS/STD/STI:
      • CHICKEN POX/SHINGLES
      • Yes No
      • ORAL HERPES (COLD SORES)
      • Yes No
      • OTHER STD/STI:
      • Yes No
      • BLOOD DISORDERS:
      • HEMOPHILIA
      • Yes No
      • EXCESSIVE BLEEDING
      • Yes No
      • ANEMIA
      • Yes No
      • BLOOD TRANSFUSION
      • Yes No
      • RESPIRATORY PROBLEMS:
      • ASTHMA
      • Yes No
      • HAY FEVER
      • Yes No
      • SINUS PROBLEMS
      • Yes No
      • LUNG PROBLEMS
      • Yes No
      • SHORTNESS OF BREATH
      • Yes No
      • TUBERCULOSIS
      • Yes No
      • EMPHYSEMA/COPD
      • Yes No
      • DIGESTIVE PROBLEMS:
      • ACID REFLUX, G.E.R.D., HYPERACIDITY
      • Yes No
      • ULCER(S)
      • Yes No
      • WEIGHT LOSS
      • Yes No
      • WEIGHT GAIN
      • Yes No
      • JOINT PROBLEMS:
      • ARTHRITIS
      • Yes No
      • BACK PROBLEMS
      • Yes No
      • ARTIFICIAL JOINT/JOINT REPLACEMENT
      • Yes No
      • NERVOUS PROBLEMS:
      • EPILEPSY
      • Yes No
      • DIZZINESS
      • Yes No
      • NEUROLOGICAL DISORDER(S)
      • Yes No
      • PHYCHOLOGICAL DISORDER(S)
      • Yes No
      • ANOREXIA/BULIMIA
      • Yes No
      • IMMUNE SYSTEM PROBLEMS:
      • HIV
      • Yes No
      • AIDS
      • Yes No
      • AUTOIMMUNE DISEASE:
      • Yes No
      • SUBSTANCE USE:
      • ALCOHOL ABUSE
      • Yes No
      • TOBACCO (SMOKING OR CHEWING)
      • Yes No
      • MARIJUANA (SMOKING, EDIBLES, ETC.)
      • Yes No
      • OTHER SUBSTANCES:
      • Yes No
  • DO YOU HAVE, OR HAVE YOU HAD, ANY OTHER MEDICAL CONDITIONS THAT WERE NOT ADDRESSED ABOVE?
  • DENTAL HISTORY
    * Note: All Responses in BLUE are required!
  • PLEASE SELECT "YES" OR "NO" AS TO WHETHER YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING:
      • ORAL TISSUES AND CONDITIONS:
      • BAD BREATH/HALITOSIS
      • Yes No
      • CANKER SORES IN MOUTH
      • Yes No
      • GROWTHS/BLISTERS/SORES IN MOUTH
      • Yes No
      • BLEEDING GUMS
      • Yes No
      • PERIODONTAL (GUM) DISEASE
      • Yes No
      • TMJ SYMPTOMS AND TREATMENT:
      • FREQUENT HEADACHES/NECKACHES
      • Yes No
      • CLICKING OR POPPING JAW
      • Yes No
      • TIRED, SORE OR PAINFUL JAW JOINT/TMJ
      • Yes No
      • PAIN AROUND EARS/TEMPLES
      • Yes No
      • CLENCHING OR GRINDING OF TEETH
      • Yes No
      • TMJ TREATMENT
      • Yes No
      • NIGHTGUARD/NTI
      • Yes No
      • RESPIRATION RELATED:
      • DRY MOUTH
      • Yes No
      • MOUTH BREATHING
      • Yes No
      • SNORING
      • Yes No
      • SLEEP APNEA
      • Yes No
      • C-PAP MACHINE
      • Yes No
      • TRAUMA, TREATMENT AND APPLIANCES:
      • INJURY TO FACE/JAW:
      • Yes No
      • BITEGUARD/SPORTSGUARD
      • Yes No
      • ORTHODONTICS (BRACES, INVISALIGN, ETC.)
      • Yes No
      • ORAL SURGERY:
      • Yes No
      • PARTIAL/FULL DENTURE(S)
      • Yes No
      • TOOTH ISSUES:
      • PAIN WITH CHEWING
      • Yes No
      • FOOD PACKING BETWEEN TEETH
      • Yes No
      • BROKEN TOOTH OR FILLING
      • Yes No
      • SENSITIVITY TO: HOT, COLD, SWEET, BITING
      • Yes No
      • VAGUE ACHE/TOOTHACHE
      • Yes No
      • SWELLING
      • Yes No
      • LOOSE TOOTH
      • Yes No
      • TREATMENT CONSIDERATIONS:
      • DENTAL ANXIETY
      • Yes No
      • EXCESSIVE GAG REFLEX
      • Yes No
      • HARD TO GET NUMB
      • Yes No
      • CLAUSTROPHOBIC
      • Yes No
      • DIFFICULTY OPENING MOUTH
      • Yes No
  • LAST VISIT TO DENTIST:
  • FOR:
  • LAST DENTAL HYGIENE APPOINTMENT:
  • WHERE:
  • DO YOU HAVE RECORDS/XRAYS AT ANOTHER OFFICE THAT WE CAN GET FOR YOU?
  • WHAT IS YOUR PRIMARY REASON FOR SEEKING DENTAL TREATMENT TODAY?
  • WHAT DO YOU WISH YOU COULD CHANGE ABOUT YOUR TEETH?
  • WHAT HAVE YOU LIKED ABOUT ANY DENTAL OFFICE YOU'VE VISITED IN THE PAST?
  • WHAT HAVE YOU LIKED LEAST ABOUT ANY OTHER OFFICE YOU'VE BEEN TO?
  • TO THE BEST OF MY KNOWLEDGE, ALL THE PRECEDING ANSWERS ARE CORRECT. IF I EVER HAVE ANY CHANGE IN MY HEALTH, OR IF MY MEDICATIONS CHANGE, I WILL INFORM MY DENTIST AT MY NEXT APPOINTMENT.
  • SIGNATURE:
  • DATE:
  • PRINT NAME:
  • FOR YOUR CONVENIENCE, WE OFFER THE FOLLOWING METHODS OF PAYMENT.
  • CASH
  • CHECK
  • CREDIT CARD
  • CARECREDIT
  • DOCPAY
  • SPRINGSTONE

Acknowledgement of Receipt of Notice of Privacy Practices

I hereby acknowledge that I have received a copy of this office's Notice of Privacy Practices.

*You may refuse to sign this acknowledgement*

Print Name Date
 
Signature
 
FOR OFFICE USE ONLY
 
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
 
___ Individual refused to sign
 
___ An emergency situation prevented us from obtaining acknowledgement
 
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Employee Name _________________________________________ Date _______________________
       
  • THANK YOU FOR FILLING OUT THIS FORM COMPLETELY.
  • THE INFORMATION YOU HAVE PROVIDED WILL HELP US SERVE YOUR DENTAL NEEDS MORE EFFECTIVELY AND EFFECIENTLY. IF YOU HAVE ANY QUESTIONS AT ANYTIME, PLEASE ASK- WE ARE ALWAYS HAPPY TO HELP.
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