Medical and Dental History - Dr. Jerry Maymi & Associates

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Dr. Jerry Maymi

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Medical and Dental History

Patient Forms >> Medical and Dental History

Medical and Dental History

Patient Name:*
Date Of Birth:*
MM slash DD slash YYYY
Physician’s Name:*
Phone*
PLEASE ANSWER ALL OF THE QUESTIONS YES OR NO AND PROVIDE ANSWERS WHERE APPLICABLE:
1. Do you consider yourself to be in good health?*
- YES
- NO
2. Are you now or have you been under a physician’s care within the past year?*
- YES
- NO
If YES, specify condition being treated:*
3. Do you have or have you ever had any heart or blood problems?*
- YES
- NO
4. Have you ever been told that you have a heart murmur?*
- YES
- NO
5. Do you have or have you ever had high blood pressure?*
- YES
- NO
6. Do you bleed or bruise easily?*
- YES
- NO
7. Are you subject to fainting?*
- YES
- NO
8. Have you ever been diagnosed as being HIV positive or having AIDS?*
- YES
- NO
9. Have you ever had hepatitis or liver disease?*
- YES
- NO
10. Have you ever had; asthma___; any blood disorder___; kidney disease___;diabetes___; joint pain/arthritis___; tuberculosis___; pneumonia___; heart attack___; heart disease or endocarditis___; rheumatic fever___; immune system disorders ___; other significant disease___?*
- YES
- NO
If YES, please specify:*
11. Do you take any medications, including birth control pills?*
- YES
- NO
If YES, Please specify name and purpose of medications:*
12. Have you ever had an unusual reaction or are you allergic to any of the following drugs?*
- YES
- NO
12.1. Have you ever had an unusual reaction or are you allergic to any of the following drugs:*
- Penicillin
- Aspirin
- Acetaminophen
- Ibuprofen
- Codeine
- Barbiturates
- Sulfa Drugs
- Other
If OTHER, please specify:*
13. Do you require antibiotic pre-medication for a heart condition or artificial valve, etc.?*
- YES
- NO
14. Have you ever taken Fosamax, Boniva, or any other drugs prescribed to decrease the resorption of bone as in osteoporosis or any drugs for metastatic bone cancer?*
- YES
- NO
15. Have you ever used or are you now using tobacco or alcohol?*
- YES
- NO
16. Is there any family history of substance abuse or misuse?*
- YES
- NO
17. Is there any personal history of substance abuse or misuse?*
- YES
- NO
18. Have you ever received counseling for use of alcohol and/or prescription drugs?*
- YES
- NO
19. Do you take any sedative medication including herbal supplements?*
- YES
- NO
20. Do you have any other allergies?*
- YES
- NO
If YES, please describe:*
21. Have you ever had a nervous breakdown or undergone psychiatric treatment?*
- YES
- NO
22. Sex*
- M
- F
Women: Are you pregnant?*
- YES
- NO
23. Are you now in pain?*
- YES
- NO
24. How long ago did you last see a dentist?*
25. Who was your previous dentist?*
26. Do you think that your teeth are affecting your general health in any way?*
- YES
- NO
27. Have you ever had any severe reaction to dental treatment or local anesthetics?*
- YES
- NO
28. Are you allergic to any local anesthetic?*
- YES
- NO
29. Do you have or have you ever had bleeding or sensitive gums?*
- YES
- NO
If YES, have you seen your physician or cardiologist for a cardiac evaluation?*
- YES
- NO
I HEREBY CERTIFY THAT THE ANSWERS TO THE FOREGOING QUESTIONS ARE ACCURATE TO THE BEST OF MY ABILITY. SINCE A CHANGE IN MY MEDICAL CONDITION OR IN MEDICATIONS I TAKE CAN AFFECT DENTAL TREATMENT, I UNDERSTAND THE IMPORTANCE OF AND AGREE TO TAKE THE RESPONSIBILITY TO NOTIFY THE DENTIST OF ANY CHANGES AT ANY SUBSEQUENT APPOINTMENT.
Signature (Patient, legal guardian or authorized agent of patient)*
Date*
MM slash DD slash YYYY
Email*
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Email
This field is for validation purposes and should be left unchanged.

Dr. Jerry Maymi

Dental Services

CEREC Same-Day Crowns
Chao Pinhole® Surgical Technique
Cosmetic Dentistry
Crowns
Bridges
Dental Cleanings and Exams
Dental Implants
Dentures and Partials
Digital X-rays
Emergency Dental Care
Extractions
Fillings
Fluoride Treatment
Mouth Guards
Pediatric Dentistry
Periodontal (Gum) Treatment
Root Canals
Sealants
Teeth Whitening
Veneers
Wisdom Teeth Extractions

Contact Us

3672 W South Jordan Parkway,
Suite 203 South Jordan,
UT 84009

doctgfm@gmail.com

Hours of Operation

Monday

12:00 PM – 8:00 PM

Tuesday

9:00 AM – 6:00 PM

Wednesday

12:00 PM – 8:00 PM

Thursday

9:00 AM – 6:00 PM

Friday

8:00 AM - 1:00 PM

Saturday

8:00 AM - 12:00 PM

Sunday

Closed

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