337 El Dorado Street, Ste 3-A
Monterey, CA 93940
770 E Romie Lane, Ste G
Salinas, CA 93901
(831) 373-2967 – Monterey
(831) 757-5291 – Salinas
Mon–Thu: 8:00 AM–4:45 PM
Fri: 8:00 AM–3:30 PM
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Have you ever been a patient at our practice?
Method of Payment
Person responsible for account?
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(if different from above)
PPO or HMO?
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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?
Damaged Heart Valves
High Blood Pressure
Low Blood Pressure
Irregular Heart Beat
Hay Fever/Sinus Problems
Blood Disorder Such
History of Drug Abuse
History of Alcohol Abuse
Chronic Fatigue/Night Sweats
Low Blood Sugar
Pain/Clicking in Jaws While
Sexually Transmitted Diseases
Removable Dental Appliance
Tumor or Growth
Mental Health Problems
Problems with Immune System
Delay in Healing
On a Diet
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?
Is there a family history of any of the following?
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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?
Are you now taking any of the following? (Please check all that apply)
Please List All Medications
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.