Medical History

Online

Medical History Form

Central Dental

280 N Central Avenue

Hartsdale NY 10530

Phone: 1-914-682-4005 Fax: 1-914-682-4301

Patient Information

First Name:*

Last Name:*

Birth Date:

The date must be less than or equal to 06/02/2025

Gender:

Email Address:

Address 1:

Pref. Phone:

Home

Work

Cell

Address 2:

Home Phone:

City:

Work Phone:

State:

Cell Phone:

Zip:

Check here to keep your personal information on this computer. Your information will only be applied on MOGO's Online Forms for future use.

Medical History
Medical History

Check [No] for all

How long since you have seen a dentist?

1 year

2 years

3 years

4 years

5+ years

Date of last complete dental exam:

Name of Previous Dentist:

Previous Dentist City & State:

Are you having problems now?

Yes

If Yes:

Is your present dental health good?

Yes

Are you unhappy with the appearance of your teeth?

Yes

Do you have Bad Breath?

Yes

Do you use any Tobacco products

Yes

Cigarettes

Cigar

Pipe

E-cigarettes

Other

Do your gums bleed or feel tender or irritated?

Yes

Do you have loose or broken fillings?

Yes

Do you experience food collecting between your teeth?

Yes

Do you wear dentures?

Yes - Partial

Yes - Full

Is your Denture:

Upper

Lower

Please rank the following in the order in which they would KEEP YOU FROM having dental treatment: (with "1" being least likely to keep you from having treatment and "5" being very likely)

Have you worn braces on your teeth (orthodontics)?

Yes

Do you wear your retainers?

Yes

Would you like your smile to look better or different?

Yes

Do you regularly use dental floss?

Yes

Allergy:

Penicillin

Novocaine

Latex

None

If none of the above, which allergies do you have:

Pharmacy Name:

Pharmacy Phone Number

Do you have any current health problems?

Yes

Are you currently under a physician's care?

Yes

If Yes:

Family Physician:

Physician Phone:

Have you ever been hospitalized?

Yes

Have you ever had major surgery?

Yes

If Yes:

Are you currently taking any medications?

Yes

If Yes, please list below:

Have you ever taken Fen-Phen/Redux?

Yes

Are you on a special diet?

Yes

Are you pregnant?

Yes

Do you use tobacco?

Yes

Do you use controlled substances?

Yes

Is there any other Medical or Dental information that you feel we should know about?

Please mark Yes or NO for each of the following which you have had or currently have:

AIDS/HIV positive:

Yes

Anaphylaxis:

Yes

Angina:

Yes

Arthritis:

Yes

Artificial Joint:

Yes

Artificial Heart Valve:

Yes

Asthma:

Yes

Blood Disease:

Yes

Breathing Problems:

Yes

Cancer:

Yes

Chemotherapy:

Yes

Chest Pains:

Yes

Cold Sores/Fever Blisters:

Yes

Congenital Heart Disorder:

Yes

Convulsions:

Yes

Cortisone Medicine:

Yes

Diabetes:

Yes

Emphysema:

Yes

Epilepsy or Seizures:

Yes

Excessive Bleeding:

Yes

Excessive Thirst:

Yes

Fainting Spells/Dizziness:

Yes

Frequent Cough:

Yes

Frequent Diarrhea:

Yes

Frequent Headaches:

Yes

Genital Herpes:

Yes

Glaucoma:

Yes

Hay Fever:

Yes

Heart Attack/Failure:

Yes

Heart Murmur:

Yes

Heart Pacemaker:

Yes

Heart Trouble/Disease:

Yes

Please mark Yes or NO for each of the following which you have had or currently have:

Hemophilia:

Yes

Hepatitis A:

Yes

Hepatitis B or C:

Yes

High Blood Pressure:

Yes

Hives or Rash:

Yes

Hypoglycemia:

Yes

Irregular Heartbeat:

Yes

Kidney Problems:

Yes

Leukemia:

Yes

Liver Disease:

Yes

Low Blood Pressure:

Yes

Lung Disease:

Yes

Mitral Valve Prolapse:

Yes

Pain in Jaw Joints:

Yes

Parathyroid Disease:

Yes

Psychiatric Care:

Yes

Radiation Treatments:

Yes

Recent Weight Loss:

Yes

Renal Dialysis:

Yes

Rheumatic Fever:

Yes

Rheumatism:

Yes

Shingles:

Yes

Sickle Cell Disease:

Yes

Sinus Trouble:

Yes

Stomach Disease:

Yes

Stroke:

Yes

Swelling of Limbs:

Yes

Thyroid Disease:

Yes

Tonsillitis:

Yes

Tuberculosis:

Yes

Tumors or Growths:

Yes

Ulcers:

Yes

Venereal Disease:

Yes