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Park Cities Oral & Maxillofacial Surgery Associates

Address:
Dallas
6140 Sherry Lane
Dallas, TX 75225

Phone:
(214) 363-2475

Hours:
Mon–Thu: 9:00 AM–4:00 PM
Fri: 8:00 AM–12:00 PM

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PATIENT INFORMATION
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Have you ever been a patient of our practice?
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Tuberculosis
Swollen AnklesArthritis
Bruise Easily
Contact Lenses
Fainting Spells
ConvulsionsEpilepsy
Is there a possibility of pregnancy?
Local Anesthetic or Numbing Medications
Latex
Have there been any changes in your general health in the past year?
Are you under the care of a physician?
Have you had any illnesses, operations, or been hospitalized in the past five years?
Do you have unhealed/recurrent injuries or inflamed areas, growths, or sore spots in or around your mouth?
Do you have a prosthetic joint/implant?
Have you had a heart valve replacement or vascular graft?
Have you ever had general anesthesia?
Have you or a family member had any unusual or serious reactions to general anesthesia?
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Rheumatic Fever
Difficulty BreathingOther
Thyroid Trouble
A Tumor or Growth
Damaged Heart Valves
Diabetes
CancerRadiation Therapy
Heart Murmur
Low Blood Sugar
Emphysema
Chronic FatigueNight Sweats
High Blood Pressure
Kidney Trouble
Blood Transfusion
On Diet
Low Blood Pressure
High Cholesterol
Blood Disorder
History of Alcohol Abuse
Chest PainAngina
On Dialysis
History of Drug Abuse
Heart Attacks
Irregular Heart Beat
Bleeding Tendency
OsteoporosisOsteopenia
Eye DiseaseGlaucoma
Cardiac Pacemaker
Osteonecrosis
Mental Health Problems
Heart Surgery
HepatitisJaundice
Stomach UlcersAcid Reflux
PneumoniaBronchitis
Contagious Diseases
Removable Dental Appliance
Infectious Mononuculeosis
Sexually Transmitted Diseases
Pain or Clicking in Jaws
Mitral Valve Prolapse
Gallbladder Trouble
Problems With Immune System
Asthma
Smoke Tobacco
SnoringSleep Apnea
Stroke
Delay in Healing
Chew Tobacco
Are you nursing?
Are you taking birth control pills?
Other Tranquilizers
Penicillin
Aspirin
Soy
Amoxicillin
Sulfa Drugs
Codeine or Other Narcotics
Sulfites
Sodium Pentothal or Valium
Other Medications
Any Other Allergies Not Listed
Are you in good health?
Hay FeverSinus Problems
Other Antibiotics
Eggs or Yolk
Any Medication Drug or Pills
Tranquilizers Sleeping Pills Antidepressants
Heart Disease
Do you wish to speak to the doctor privately about anything?
Is this visit related to an accident?
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Any Natural Product Herbal Supplement or Homeopathic Remedy
Blood Thinners Coumadin Plavix Aspirin
Bone Density Medications or Bisphosphonates Such as Fosamax
Diet Pills
Cancer
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Anesthesia Problems
If you are having surgery today, have you had anything to eat or drink in the past six hours?
Is there any condition concerning your health that the doctor should be told about?
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