5707 Marconi Ave # B, Carmichael, CA 95608 | (916) 973-0156   
Edward M Orgon, DDS
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New Patient Health Information Form

This field is for validation purposes and should be left unchanged.
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate. records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may
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Name(Required)
Address
Insurance Company Address
Subscriber name (Employee)
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Emergency Contact(Required)
Are completing this form for another person?
If you are completing this form for another person, what is your relationship to that person?
Do you have any of the following diseases or problems:
Check DK if you DON'T know the answer.
Active Tuberculosis(Required)
Persistent cough greater than a 3 week duration(Required)
Cough that produces blood(Required)
Been exposed to anyone with tuberculosis(Required)
If you answer yes to any of the 4 items above, please stop and submit this form now.

Dental Information

Do your gums bleed when you brush or floss?(Required)
Are your teeth sensitive to cold, hot, sweets, or pressure?(Required)
Is your mouth dry?(Required)
Have you ever had orthodontic (braces) treatment?(Required)
Have you had any periodontal (gum) treatments?(Required)
Have you had any problems associated with previous dental treatment?(Required)
Is your home water supply fluoridated?(Required)
Do you drink bottled or filtered water?(Required)
If yes, how often? (Check one:)(Required)
Are you currently experiencing dental pain or discomfort?(Required)
Do you have earaches or neck pains?(Required)
Do you have any clicking, popping or discomfort in the jaw?(Required)
Do you brux or grind your teeth?(Required)
Do you have sores or ulcers in your mouth?(Required)
Do you wear dentures or partials?(Required)
Have you ever had a serious injury to your head or mouth?(Required)
Do you participate in active recreational activities?(Required)
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Medical Information

Please check your response to indicate if you have or have not had any of the following diseases or problems.
Are you now under the care of a physician?(Required)
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Physician Name
Physician Address
Are you in good health?(Required)
Has there been any change in your general health within the past year?(Required)
Have you had a serious illness, operation or been hospitalized in the past 5 years?(Required)
Are you taking or have you recently taken any prescription or over the counter medicine(s)?(Required)
Do you wear contact lenses?(Required)
Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?(Required)
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Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax® , Actonel® , Atelvia, Boniva® , Reclast, Prolia) for osteoporosis or Paget’s disease?(Required)
Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia® , Zometa® , XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?(Required)
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Allergies. Are you allergic to or have you had a reaction to:

Do you use controlled substances (drugs)?(Required)
Do you use tobacco (smoking, snuff, chew, bidis)?(Required)
If so, how interested are you in stopping?(Required)
Do you drink alcoholic beverages?(Required)
Women Only: Are you

Women Only

Are you pregnant?(Required)
Taking birth control pills or hormonal replacement?(Required)
Nursing?(Required)

Allergies

Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.
Local anesthetics(Required)
Aspirin(Required)
Penicillin or other antibiotics(Required)
Barbiturates, sedatives, or sleeping pills(Required)
Sulfa drugs(Required)
Codeine or other narcotics(Required)
Metals(Required)
Latex (rubber)(Required)
Iodine(Required)
Hay fever/seasonal(Required)
Animals(Required)
Food(Required)
Other(Required)

Diseases or Problems

Please check your response to indicate if you have or have not had any of the following diseases or problems.
Artificial (prosthetic) heart valve
Damaged valves in transplanted heart
Previous infective endocarditis
Congenital heart disease (CHD) Unrepaired, cyanotic CHD
Repaired (completely) in last 6 months
Repaired CHD with residual defects
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
Cardiovascular disease(Required)
Angina(Required)
Arteriosclerosis(Required)
Congestive heart failure(Required)
Damaged heart valves(Required)
Damaged heart valves(Required)
Heart murmur(Required)
Low blood pressure(Required)
High blood pressure(Required)
Other congenital heart defects(Required)
Mitral valve prolapse(Required)
Pacemaker(Required)
Rheumatic fever(Required)
Rheumatic heart disease(Required)
Abnormal bleeding(Required)
Anemia(Required)
Blood transfusion(Required)
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Hemophilia(Required)
AIDS or HIV infection(Required)
Arthritis(Required)
Autoimmune disease(Required)
Systemic lupus erythematosus(Required)
Rheumatoid arthritis(Required)
Asthma(Required)
Bronchitis(Required)
Emphysema(Required)
Sinus trouble(Required)
Tuberculosis(Required)
Cancer/Chemotherapy/ Radiation Treatment(Required)
Chest pain upon exertion(Required)
Chronic pain(Required)
Diabetes Type I or II(Required)
Malnutrition(Required)
Eating disorder(Required)
Gastrointestinal disease(Required)
G.E. Reflux/persistent heartburn(Required)
Ulcers(Required)
Thyroid problems(Required)
Stroke(Required)
Glaucoma(Required)
Hepatitis, jaundice or liver disease(Required)
Epilepsy(Required)
Fainting spells or seizures(Required)
Neurological disorders(Required)
Sleep disorder(Required)
Do you snore?(Required)
Mental health disorders(Required)
Recurrent Infection(Required)
Kidney problems(Required)
Night sweats(Required)
Osteoporosis(Required)
Persistent swollen glands in neck(Required)
Severe headaches/ migraines(Required)
Severe or rapid weight loss(Required)
Sexually transmitted disease(Required)
Excessive urination(Required)
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?(Required)
Name of physician or dentist making recommendation(Required)
Please explain:
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.
Clear Signature
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Edward Orgon, DDS
5707 Marconi Ave., Ste B
Carmichael, CA 95608
Phone number: (916) 973-0156

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