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Medical History Form

Form 2 of 4

Please complete this medical history form so our team can provide safe and appropriate surgical care. If you have any questions, call us at 707-545-4625.

General Information
Have you been a patient in the hospital during the past year?
In the past two (2) years, have you had a serious illness requiring a physician's care?
Medical Conditions

Indicate which of the following you have had or have at present.

Stroke
Heart Disease or Attack
Angina Chest Pain
Heart Murmur
High/Low Blood Pressure
Mitral Valve Prolapse
Heart Pacemaker
Heart Surgery
Rheumatic Fever
Artificial Heart Valve
Artificial Joints (hip, knee, etc.)
TMJ (jaw joint) Problems
Snoring/Sleep Apnea
Severe/Frequent Headaches
Psychiatric Problems
Ulcers
Diabetes
Thyroid Problems
Glaucoma
Cancer
Chemotherapy
Radiation Therapy
Lyme Disease
Emphysema
Tuberculosis
Asthma
Allergies or Hives
Sinus Problems
Hepatitis
Liver Disease
H.I.V. Positive/A.I.D.S.
Venereal Disease
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia
Anemia
Sickle Cell Disease
Bruise Easily
Epilepsy or Seizures
Fainting or Dizzy Spells
Drug Addiction
Have you ever taken prescription medication for weight reduction (diet pills)?
Have you ever taken prescription medication for osteoporosis (bisphosphonate: fosamax, zoireta, areta)?
Do you take health food supplements (ginkgo, St. Johns wort, vitamin E, ginseng)?
Medication Allergies & Sensitivities

Are you sensitive or allergic to any of the following medications?

Penicillin
Erythromycin
Tetracycline
Sulfa
Codeine
Aspirin/Ibuprofen
Tylenol/Acetaminophen
Steroids
Latex
Local Anesthetics
Food (e.g. egg, soy)
Misc/Other Questions
Do you smoke?
Do you drink alcohol?
Do you take recreational drugs?
Do you have or have you had any disease, condition or problem not listed?
For Women Only
Are you taking birth control pills?
Are you nursing?
Are you pregnant?

I understand the above information is necessary to provide safe surgical treatment. I have answered all questions truthfully and to the best of my knowledge.

Schedule Your Visit

Appointment Request

Take the next step toward healthier function, greater comfort, and renewed confidence with care designed around your needs. Whether you have been referred for oral surgery in Santa Rosa, CA, are exploring dental implants, or need prompt attention for wisdom teeth or extractions, our team is ready to help. We explain your options clearly, answer questions thoroughly, and make scheduling simple so you can begin treatment with peace of mind today with confidence and clarity throughout treatment.

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