Buffalo Prairie Dental - Dr. Ben Pyatt and Dr. Ed Pyatt

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Buffalo Prairie Dental

Buffalo Prairie Dental Medical History

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Name *

Birth Date *

Date Created: *

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body, Health problems that you may have, or medication that you may be taking.

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Do you have a Primary care doctor? Who is your Primary care doctor? *

Yes
No

If Yes

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Have you ever been hospitalized or had a major operation? *

Yes
No

If Yes

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Have you ever had a serious head or neck injury? *

Yes
No

If Yes

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Are you taking any medications, pills, or drugs? *

Yes
No

If Yes

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Do you take, or have you taken, Phen-Fen or Redux? *

Yes
No

If Yes

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Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? *

Yes
No

If Yes

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Are you on a special diet? *

Yes
No

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Do you use tobacco? *

Yes
No

Women: Are you...

Pregnant/Trying to get pregnant?
Nursing?
Talking Oral Contraceptives?

Are you allergic to any of the following?

Aspirin
Metal
Penicillin
Latex
Codeine
Acrylic
Sulfa Drugs
Local Anesthetics

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Do you use controlled substances? *

Yes
No

If Yes

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Other?

Other?

If Yes

Do you have a hearing limitation?

Yes
No

Do you have, or have you had, any of the following?

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AIDS/HIV Positive

Yes
No

Alzheimer's Disease

Yes
No

Anemla

Yes
No

Angina

Yes
No

Arthritis

Yes
No

Artificial Heart Valve

Yes
No

Artificial Joint

Yes
No

Asthma

Yes
No

Blood Disease

Yes
No

Blood Transfusion

Yes
No

Breathing Problems

Yes
No

Bruise Easily

Yes
No

Cancer

Yes
No

Chemotherapy

Yes
No

Chest Pains

Yes
No

Cold Sores/Fever Blisters

Yes
No

Congenital Heart Disorder

Yes
No

Convulsions

Yes
No

COPD

Yes
No

Cortisone Mediane

Yes
No

Diabetes

Yes
No

Drug Addiction

Yes
No

Easily Winded

Yes
No

Emphysema

Yes
No

Epilepsy or Seizures

Yes
No

Excessive Bleeding

Yes
No

Excessive Thirst

Yes
No

Fainting Spells/Dizziness

Yes
No

Frequent Cough

Yes
No

Frequent Diarrhea

Yes
No

Frequent Headaches

Yes
No

Genital Herpes

Yes
No

Glaucoma

Yes
No

Hay Fever

Yes
No

Heart Attack/Failure

Yes
No

Heart Murmur

Yes
No

Heart Pacemaker

Yes
No

Heart Trouble/Disease

Yes
No

Hemophilia

Yes
No

Hepatitis A

Yes
No

Hepatitis B or C

Yes
No

Herpes

Yes
No

High Blood Pressure

Yes
No

High Cholesterol

Yes
No

Hives or Rash

Yes
No

Hypoglycemia

Yes
No

Irregular Heartbeat

Yes
No

Kidney Problems

Yes
No

Leukemia

Yes
No

Liver Disease

Yes
No

Low Blood Pressure

Yes
No

Lung Disease

Yes
No

Mitral Valve Prolapse

Yes
No

Osteoporosis

Yes
No

Pain in Jaw Joints

Yes
No

Farathyroid Disease

Yes
No

Psychiatric Care

Yes
No

Radiation Treatments

Yes
No

Recent Weight Loss

Yes
No

Renal Dialysis

Yes
No

Rheumatic Fever

Yes
No

Scarlet Fever

Yes
No

Sickle Cell Disease

Yes
No

Sinus Trouble

Yes
No

Spina Bifida

Yes
No

Stomach/Intestinal Disease

Yes
No

Stroke

Yes
No

Swelling of Limbs

Yes
No

Thyroid Disease

Yes
No

Tonsillitis

Yes
No

Tuberculosis

Yes
No

Tumors or Growths

Yes
No

Ulcers

Yes
No

Venereal Disease

Yes
No

Yellow Jaundice

Yes
No

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Have you ever had any serious illness not listed above?

Yes
No

If Yes

Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.