Norwood Dental
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About Us
Meet Our Team
Dr. Brandon Bussler
Dr. Dan Ross
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Office News
Dental Services
Composite Fillings
Crowns
Dental Bridges
Dental Implants
Dentures/Partials
Emergency Dental Services
Preventative Care
Root Canals
Tooth Extractions
Advanced Technologies
3D Cone Beam Imaging
OraVerse® Reversable Numbing Agent
The Wand® Painless Injections
Cerec® Same Day Crowns
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Patient Forms
No Insurance
Contact
Menu
About Us
Meet Our Team
Dr. Brandon Bussler
Dr. Dan Ross
Tour The Office
Office News
Dental Services
Composite Fillings
Crowns
Dental Bridges
Dental Implants
Dentures/Partials
Emergency Dental Services
Preventative Care
Root Canals
Tooth Extractions
Advanced Technologies
3D Cone Beam Imaging
OraVerse® Reversable Numbing Agent
The Wand® Painless Injections
Cerec® Same Day Crowns
Patient Information
Patient Forms
No Insurance
Contact
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Medical History
Patient First Name:
(Required)
Last Name:
(Required)
Email
(Required)
Physician Name:
Clinic Name:
Are you Allergic to any of the following?
Amoxicillin
Clindamycin
metals
Penicillin
Aspirin
Ibuprofen
Jewelry
Sulfa Drugs
Codeine
Tylenol
Latex
Dental Anesthetics
Other
Please list all current medications you are taking:
Do you have or have you experienced any of the following?
Acid Reflux
Yes
No
Drug Abuse
Yes
No
Memory Loss
Yes
No
Alcohol Abuse
Yes
No
Emphysema
Yes
No
Mitral Valve Prolapse
Yes
No
Arthritis
Yes
No
Epilepsy
Yes
No
Occlusal Appliance
Yes
No
Heart
Yes
No
Glaucoma
Yes
No
Psychiatric Care
Yes
No
Asthma
Yes
No
Headaches
Yes
No
Radiation Treatment
Yes
No
Blood Transfusion
Yes
No
Heart Murmur
Yes
No
Rheumatic Fever
Yes
No
Chemotherapy
Yes
No
Heart Surgery
Yes
No
Sinus Problems
Yes
No
Congenital Heart Defect
Yes
No
Hepatitis Type
Yes
No
Hepatitis Type
Snoring
Yes
No
Depression
Yes
No
HIV/AIDS
Yes
No
Stroke
Yes
No
Diabetes
Yes
No
High Blood Pressure
Yes
No
Thyroid Problems
Yes
No
Anxiety
Yes
No
Hearing Impaired
Yes
No
Tuberculosis (TB)
Yes
No
Kidney Problems
Yes
No
Ulcers
Yes
No
Lever Disease
Yes
No
Vertigo
Yes
No
Has any doctor recommended pre-medication with antibiotics before dental appointments for any reason? Explain, if yes:
(Required)
List any serious medical condition(s) you have experienced:
Women: Are you pregnant now?
How many months?
Any complications following dental treatment?
Anything else you would like us to know?
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.
Date
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Patient/Guardian/Parent Signature
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