Daniel Castro D.D.S, P.A

6901 Helen of Troy, BLDG. C

El Paso, Texas, 79911

915-581-8070

MEDICAL – DENTAL HISTORY

Patient's Name
DOB:
SSN
Phone:
E-mail:

INSTRUCTIONS:

To receive treatment in this office you must answer all questions on this history form. The questions asked relate directly to the safe and effective treatment you are to receive in the office‐to the best of your ability, honest answers must be given. If you are unsure of the questions, unsure of your answer, or whether the questions relate to your medical condition, you are to discuss the matter with the doctor. Some of the questions may not relate to your medical condition; in the event you are to write “N/A” (not applicable) in the space provided. All questions must be answered. To properly evaluate your current health status it may be necessary for the dentist to contact your physician. Included on this form is “Permission to Release Information.”Please sign it in the presence of a member of the office staff. ALL INFORMATIONS YOU SUPPLY ON THIS FORM OR INFORMATION OBTAINED BY YOUR PHYSICIAN AND THE SUBSEQUENT INTERVIEW BY THE DENTIST WILL BE HELD IN THE STRICTEST CONFIDENCE, AND WILL NOT BE DISCLOSED WITHOUT YOUR WRITTEN PERMISSION.

Physician Name
Phone
Address
Date of last visit to your MD
Purpose of visit
Do you suffer from any disability?
If yes, describe
PLEASE SELECT EACH OF THE FOLLOWING: YES OR NO
Rheumatic Fever
Joint Replacement (hip, knee etc)
Heart Murmur
Surgery
Type
YR
Arthritis/Rheumatism
Mitral Valve Prolapse
Hepatitis/Liver disease
Type
How long ago?
HIV Positive/AIDS
Migraine headache
Neck/Head Pain
Anemia/Blood Disease
Tuberculosis/Lung Disease
Kidney Dysfunction/ Disease/ Dialysis
Hay Fever/Allergies
Low Blood Pressure
High Blood Pressure
Do you use tobacco
Implants (teeth, breast, hair, etc.)
Cancer
Radiation
Chemotherapy
Epilepsy/Seizures
Fainting/Nervousness
Heart Disease/Heart Attack
Angina, Pacemaker, Heart Surgery or Irregular beats
Herpes Virus
Asthma/Respiratory problems
Diabetes
Type
Stroke/Convulsions
STD/Venereal Disease
Thyroid Disease
Frequently Tired
Liver Disease
Pregnant?
Of months
Are you Nursing?
Are you taking Birth Control Pills?
Other Medical Condition, past or present
(If yes, has your physician told you that premedication is needed prior to dental treatment?)
Allergic to
Other's Specify:
Date:
Have you ever needed PRE MEDICATION (antibiotic) prior to dental treatment?
If you have answered yes to any of the above questions please explain:

Please list all medications, reason for taking them, mg. you are taking, and frequency taken

(Prescription and non‐prescription)
DENTAL HISTORY
Name of the previous dentist
Reason for visit
PLEASE SELECT EACH OF THE FOLLOWING: YES OR NO
Had an allergic reaction to treatment?
Complications during treatment?
Does food catch between your teeth?
Do you grind your teeth or clench your jaws?
Do your teeth ache?
Had abnormal bleeding?
Do your gums bleed on brushing or eating?
Have your teeth shifted?
Are any of your teeth sensitive to hot, cold, or pressure?
Are there any sores or growths in your mouth?
If you have answered yes to any of the above questions please explain:

NOTE: A change in your health information obtained from me, and information about my dental treatment to third party payers, and/or other health practitioners.

Signature

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Person completing the form:

Witness Signature

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Witness Name
If other than patient, indicate relationship
Date

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