Medical History

Please fill out the form below

Patient Information

First Name *

Last Name *

Middle Initial

Email *

Health Overview

Your Current Physical Health:

Good Fair Poor

Do You Have A Personal Physician?

No Yes

Currently Under The Care Of A Physician?

No Yes

Do You Use Tobacco In Any Form?

No Yes

Had Any Metal Rods, Pins Or Implants Placed?

No Yes

Are You Taking Any Medications?

No Yes

Have You Ever Had Any Surgical Procedures?

No Yes

Medical Conditions

Do you have any of the following? Check all that apply.

Abnormal Bleeding Alcohol Abuse Allergies Anemia Angina Pectoris Arthritis Artificial Heart Valve Asthma Blood Transfusion Cancer Chemotherapy Colitis Congenital Heart Defect Diabetes Difficulty Breathing Drug Abuse Emphysema Epilepsy Facial Surgery Fainting Spells Fever Blisters Frequent Headaches Glaucoma HIV+/AIDS Heart Attack Heart Murmur Heart Surgery Hemophilia Hepatitis A Hepatitis B Hepatitis C High Blood Pressure Joint Replacement Kidney Problems Liver Disease Low Blood Pressure Mitral Valve Prolapse Pace Maker Psychiatric Problems Radiation Therapy Rheumatic Fever Seizures Sexually Transmitted Disease Shingles Sickle Cell Disease Sinus Problems Stroke Thyroid Problems Tuberculosis Ulcers

Other:

Allergies

Are you allergic to any of the following? Check all that apply.

Aspirin Codeine Dental Anesthetics Erythromycin Jewelry Latex Metals Penicillin Tetracycline

Other:

If Female, Please Answer

Are you taking Birth Control Pills?

Yes No

Are you pregnant?

No Yes

Are you nursing?

Yes No

Nova Dental Studio

Address

Michael J. Paesani, DMD – NOVA Dental Studio
200 Little Falls St #101
Falls Church, VA 22046

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Contact Us

info@novadentalstudio.com

(703) 237-7725

2026 Nova Dental Care copyright all. right reserved

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