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Mosa Oral Maxillofacial & Dental Implant Surgery

Address:
Monterey
337 El Dorado Street, Ste 3-A
Monterey, CA 93940

Salinas
770 E Romie Lane, Ste G
Salinas, CA 93901

Phone:
(831) 373-2967 – Monterey
(831) 757-5291 – Salinas

Hours:
Mon–Thu: 8:00 AM–4:45 PM
Fri: 8:00 AM–3:30 PM

Contact Us

Page 1 of 4

General Patient Information

Salutation

Gender

Have you ever been a patient at our practice?

Method of Payment

Person Responsible For The Account

Person responsible for account?

Page 2 of 4

Spouse Or Other Guarantor Information

(if different from above)

Insurance Information

Student

Marital Status

Employed

PPO or HMO?

Primary Dental Insurance

Gender

Secondary Dental Insurance

Gender

Primary Medical Insurance

Gender

Secondary Medical Insurance

Gender

Page 3 of 4

Patient Health History

To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Are you in good health?

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 illness, operation, or been hospitalized in the past five years?

Do you have unhealed/recurrent injuries, inflamed areas, growths, or sore spots in or around your mouth?

Have you ever had general anesthesia?

If you are having surgery today, have you had anything to eat or drink in the last eight hours?

Have you had or do you currently have:

Rheumatic Fever

Damaged Heart Valves

High Blood Pressure

Low Blood Pressure

Chest Pain/Angina

Heart Attack(s)

Irregular Heart Beat

Cardiac Pacemaker

Heart Surgery

Bronchitis/Chronic Cough

Asthma

Hay Fever/Sinus Problems

Tuberculosis

Fainting Spells

Emphysema

Difficulty Breathing/Other

Blood Transfusion

Blood Disorder Such

Bruise Easily

Bleeding Tendency

Jaundice/Hepatitis/Liver

Infectious Mononucleosis

Gallbladder Trouble

Smoke Tobacco

History of Drug Abuse

History of Alcohol Abuse

Chronic Fatigue/Night Sweats

Kidney Trouble

Stroke

Thyroid Trouble

Heart Murmur

Low Blood Sugar

Contact Lenses

On Dialysis

Swollen Ankles/Arthritis/Joint

Pain/Clicking in Jaws While

Stomach Ulcers

Sexually Transmitted Diseases

Malignant Hyperthermia

Contagious Diseases

Removable Dental Appliance

Tumor or Growth

Mental Health Problems

Problems with Immune System

Anxiety/Depression

Eye Disease/Glaucoma

Convulsions/Epilepsy

Diabetes

Delay in Healing

On a Diet

X-Ray Treatment/Chemotherapy


Do you have sleep apnea?

Please Pick One

Do you have a prosthetic joint/implant?

Have you ever had a heart valve replacement or vascular graft?

Is there any other condition concerning your health that the doctor should be told about?

Do you wish to speak to the doctor privately about anything?

Family Health History

Is there a family history of any of the following?

Cancer

Diabetes

Heart Disease

Anesthetic Problems

Page 4 of 4

Women Only

WOMEN NOTE: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.

Are you taking birth control pills?

Is there a possibility of pregnancy?

Are you nursing?


Allergies

Allergies

Medications

Are you now taking any of the following? (Please check all that apply)

Medication

Please List All Medications





In Case Of Emergency

I certify that I have read and understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon or any other member of his/her staff responsible for any errors or omissions that I have made in the completion of this form.