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5280 Route 309, Center Valley, PA 18034
610-282-1278
M: 9am-5pm | T: 7am-7pm | W: 9am-5pm | TH: 7am-7pm | F: 9am-1pm
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Cirocco Dental Center
Center Valley Oral Health & Cosmetic Dentistry
About
Why Choose Cirocco Dental Center
Meet Dr. Cirocco
Meet Dr. Kilpatrick
Meet Our Staff
Patient Testimonials
Our Technology
Patient Info
Patient Testimonials
New Patients
Oral Surgery Post Care Instructions
Forms
Pricing
Insurances Accepted
Smile Healthy Plan
Our Services
Emergency Dental Services
Fillings
Crowns
Extractions
Dental Hygiene
Gum Disease & Gum Health
Scaling & Root Planing
Dentures & Partials
Dental Implants
Root Canals & Endodontic Treatments
Teeth Whitening & Bleaching
Teeth Grinding & Sleep
Treatment For TMJ
Reveal Clear Aligners
Promotions
Current Promotions
Referral Program
Contact
Book an Appt.
About
Why Choose Cirocco Dental Center
Meet Dr. Cirocco
Meet Dr. Kilpatrick
Meet Our Staff
Patient Testimonials
Our Technology
Patient Info
Patient Testimonials
New Patients
Oral Surgery Post Care Instructions
Forms
Pricing
Insurances Accepted
Smile Healthy Plan
Our Services
Emergency Dental Services
Fillings
Crowns
Extractions
Dental Hygiene
Gum Disease & Gum Health
Scaling & Root Planing
Dentures & Partials
Dental Implants
Root Canals & Endodontic Treatments
Teeth Whitening & Bleaching
Teeth Grinding & Sleep
Treatment For TMJ
Reveal Clear Aligners
Promotions
Current Promotions
Referral Program
Contact
Medical History Form
Download All PDF Forms
Medical History Form
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ALTHOUGH DENTAL PERSONNEL 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 DENTISTRY YOU WILL RECEIVE. THANK YOU FOR ANSWERING THE FOLLOWING QUESTIONS.
Medical Questions
Check all that apply.
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?
Do you take, or have you taken, Phen-Fen or Redux?
Medical Questions
Check all that apply.
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing Bisphosphonates?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
For female patients only.
Check all that apply.
Pregnant/Trying to Conceive
Nursing
Taking Oral Contraceptives
None of the Above
Allergies
Allergies
Check all that apply.
Aspirin
Penicillin
Codeine
Acrylic
Metal
Allergies
Check all that apply.
Latex
Sulfa Drugs
Local Anesthetics
Other Allergies
Conditions
Check all that apply.
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Value
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breath Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsion
Cortisone Medicine
Conditions
Check all that apply.
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Conditions
Check all that apply.
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Hash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Conditions
Check all that apply.
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow - Jaundice
Have you ever had any other serious illness(es) not listed above?
Additional Comments:
My Information
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I AGREE. By clicking here and submitting this form, I agree that, to the best of my knowledge, the questions on this form have been accurately 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 in medical status.
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