Dr. Dustin Nelson Dental and Health History Information Form

	Dr. Nelson is featured in New Beauty Magazine!
	Health & Dental History Questionnaire

Please enter the spam-filter code:
Have you been under the care of a medical doctor during the past two years?	Yes No
If yes, please describe what the medical care was for?
Your doctor's full name:
Your doctor's phone number:
Are you taking any medication now, including regular doses of aspirin?	Yes No
If yes, please list the names of medications and dosages?
Do you have any allergic reactions to any medication or substance?	Yes No
If yes, please list the medications or substances?
Please indicate which of the following health problems or conditions you have had in the past or have at present:
Heart Concerns or Problems	Yes No
Congenital Heart Disease	Yes No
Heart Murmur	Yes No
High Blood Pressure	Yes No
Mitral Valve Prolapse	Yes No
Artificial Heart Valve	Yes No
Pacemaker	Yes No
Stroke	Yes No
Asthma	Yes No
Liver Disease or Jaundice	Yes No
Latex Sensitivity	Yes No
Artificial Joints	Yes No
Kidney Trouble	Yes No
Radiation or Chemo Therapy	Yes No
Epilepsy	Yes No
Diabetes	Yes No
Hepatitis	Yes No
AIDS or HIV	Yes No
Sickle Cell Disease	Yes No
Neurological Disorder	Yes No
Psychiatric or Psychological Care	Yes No
Headaches	Yes No
Jaw Pain	Yes No
Jaw Popping	Yes No
Limited Jaw Opening	Yes No
Congested Ears	Yes No
Dizziness	Yes No
Ringing Ears	Yes No
Loose Teeth	Yes No
Posture Problems	Yes No
Teeth Clenching	Yes No
Teeth Grinding	Yes No
Facial Pain	Yes No
Sensitive Teeth	Yes No
Neck Pain	Yes No
Bell's Palsy	Yes No
Difficulty Swallowing	Yes No
Difficulty Chewing	Yes No
Trigeminal Neuralgia	Yes No
Tingling in Arms or Fingers	Yes No
Insomnia or Frequent Waking	Yes No
Have you had braces on your teeth	Yes No
Do you see a chiropractor	Yes No
Does floss shred when you use it?	Yes No
Does food pack or catch between you teeth?	Yes No
Do you smoke our chew tobacco?	Yes No
Do your gums bleed?	Yes No
Does your breath concern you?	Yes No
Do you have or have you had any disease, condition or problem not listed here?	Yes No
If yes, please provide details:
Questions for ladies:
Are you pregnant?	Yes No
Are you nursing?	Yes No
Are you taking birth control pills?	Yes No
Additional information or questions:
Is there anything else you would like to tell us or ask about?
Your contact information:
Mr./Ms./Mrs.
Your first name:
Your middle name:
Your last name:
Address:
Additional address if needed:
City:
State or Province:
ZIP or Postal Code:
Country if other than the USA:
Social Security Number:
Date of birth:
Your email address:
The best phone number to contact you:
By submitting this form, you agree to the following statement: I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider who may release such information to you. I will notify the doctor of any change in my health or medication.

Would you prefer to do this on paper?

If you prefer, you can send this information to us by FAX or mail. You can download a health and dental history information form here in Adobe Acrobat PDF.
If you don't have Adobe Acrobat Reader, you can get the latest version here. It is a free download.

• Bone Regeneration • California Cosmetic Dentist • Celebrity Smile Makeovers
• Dental Spa • Empress Crowns • Gum Disease • Laser Dentistry • LVI Dentist
• MAC Veneers • Neuromuscular Dentistry • Pasadena Dentist • Root Canal Treatment
• Treating Gum Disease • Site Map • Links • Link Exchange