Online Registration

Online

Medical History Form

Yenzer Family Dental

17600 Chesterfield Airport Rd

Chesterfield MO 63005

Phone: 1-636-778-3019 Fax: 1-636-778-3332

Patient Information

First Name:*

Last Name:*

Birth Date:

Gender:

Email Address:

Address 1:

Pref. Phone:

Home

Work

Cell

Address 2:

Home Phone:

City:

Work Phone:

State:

Cell Phone:

Zip:

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Medical History
Medical History

Check [No] for all

How long has it been since you have seen a Dentist?

Date of last complete dental exam:

Name of Previous Dentist:

Are you having problems now?

Yes

If Yes:

Are you unhappy with the appearance of your teeth?

Yes

Are your teeth somewhat yellowed, darkened, or stained?

Yes

Any unpleasant experiences in a dental office?

Yes

Does food catch between your teeth?

Yes

Are your teeth sensitive to cold or sweets?

Yes

Have you experienced pain or discomfort in your jaw joint?

Yes

Are there spaces between any of your teeth?

Yes

Do you grind your teeth? Are your teeth chipped or worn down?

Yes

Are your gums red, puffy or do they bleed?

Yes

Do you have a "gummy" smile -showing to much gum tissue or having gums that are too thick?

Yes

Do you have any gray, black or silver dental fillings in your teeth that you want to replace?

Yes

Do you have any old crowns that have dark edges at the top that do not look natural?

Yes

Do you smoke? How much/ Often?

Do you use smokeless tobacco? How much/often?

Do you drink alcohol? How much/often?

Have you taken any of the following

Coumadin

Zometa

Actonel

Boniva

Cortico-Steroid

Vioxx

Fosamax

Abnormal bleeding

Yes

Alcohol/Drug Abuse

Yes

Anemia

Yes

Allergies

Yes

Artificial bones/Joints /Valves

Yes

Asthma

Yes

Blood Transfusion

Yes

Bone/ Joint Disease

Yes

Congenital Heart Defect

Yes

Cancer/Chemotherapy

Yes

Diabetes

Yes

If yes A1C

Difficulty breathing

Yes

Eating Disorder

Yes

Emphysema

Yes

Epilepsy

Yes

Hemophilia

Yes

Fainting Spells

Yes

Nervous Disorder

Yes

Pacemaker/ICD

Yes

Psychiatric care

Yes

Radiation treatment

Yes

Rashes

Yes

Rheumatic/ Scarlet Fever

Yes

Seizures

Yes

Sexually transmitted Diseases

Yes

Shingles

Yes

Gingivitis

Yes

Periodontal Disease

Yes

Glaucoma

Yes

Headaches

Yes

Heart Attack

Yes

Heart Murmur:

Yes

Heart Surgery

Yes

Hepatitis

Yes

If yes what type?

Herpes/Fever blisters

Yes

High Blood pressure

Yes

AIDS/HIV positive:

Yes

Pain in Jaw Joints:

Yes

Kidney Problems:

Yes

Liver Disease:

Yes

Low Blood Pressure:

Yes

Lupus

Yes

Mitral Valve Prolapse:

Yes

Sinus Problems

Yes

Spasms/Cramps

Yes

Stroke:

Yes

Thyroid Disease:

Yes

Tumors or Growths:

Yes

Ulcers:

Yes

Other- Please list

Do you consider your current overall physical health to be

Good

Fair

Poor

Are you currently under the active care of a physician or do you have any present health issues?

Yes

if yes, Please explain

Do you need to be Pre-medicated with antibiotics for any heart or other medical condition prior to dental treatment?

Yes

Are you taking any prescriptions or over-the-counter medication?(including ibuprofen,diet supplements,etc.)

Yes

Please list each one

Are you pregnant or nursing?

Yes

If pregnant, which trimester?

1st

2nd

3rd

And Due date?

Are you allergic to any of the following?

Aspirin

Codeine

Dental Anesthetics

Latex

Penicillin

tetracycline

Sulfites

Any metals

Erythromycin

Have you had any adverse reactions to local anesthetic?

Yes

If Yes, please explain:

Are you aware of being allergic to any other medications or substances?

Yes

If Yes, please list below: