Soft Tissue Grafting
Corrective Jaw Surgery
Cleft Lip & Palate
Biopsy for Oral Pathology
Platelet Rich Plasma
Surgeons & Team
Steven E. Christensen, DDS
Bryan S. Christensen, DMD
6243 S. Redwood Road, Suite 100
Salt Lake City, UT 84123
Although dental personnel primarily treat the area in & around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician’s care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Have you ever taken Fosamax, Boniva, Actonel, Xgeva or any medications containing Bisphosphonates?
Do you take, or have you taken, Phen-Fen or Redux?
Do you ever smoke or use tobacco?
Do you drink alcohol?
Are you on a special diet?
Do you use controlled substances?
Trying to get pregnant
Taking oral contraceptives
Do you have, or have you had, any of the following?
Congenital Heart Disorder
Hay Fever / Sinus Issues
High Blood Sugar
Heart Pace Maker*
Low Blood Sugar
Artificial Heart Valve*
High Blood Pressure
Low Blood Pressure
Hepatitis B or C
Epilepsy or Seizures
Swelling of Limbs
Hives or Rash
Mitral Valve Prolapse*
Immune system Disorder
Pain in Jaw Joints / TMJ
Tumors or Growths
Cold Sores / Blisters
Glaucoma / Eye Disorder
Recent Weight Loss
Do you have any serious previous or present medical or dental problems that: 1) are not listed above or, 2) you think the Dr. should know about?
Please tell us about any other medical or dental problems
Is there anything you wish to speak about in private with the doctor?
I am the patient or parent/legal guardian authorized to provide the information requested. To the best of my knowledge, the questions on this form have been accurately and completely answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes that may occur in my medical status. I understand that payment for professional services are my sole responsibility and are due as services are rendered. Non-payment for services may result in additional collection fees. We do not render services on the basis that insurance companies will pay our fees, but we will be happy to assist you in filing claims for your insurance reimbursement. I authorize Dr. Christensen to diagnose and provide dental treatment for myself (or patient) including any necessary x-rays or photographs.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN
Date Format: MM slash DD slash YYYY
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Utah Oral Surgery & Dental Implant Center