Patient History Form

- Are you advised to take antibiotics prior to dental treatment?

- Have you experienced a fast heart rate/ rush after dental anesthetics?

- Do you have getting numb for dental treatment?

- Have you had surgery or been hospitalized in the past five years?

- Are you taking any blood thinners like Coumadin? If yes what are you taking?

- Are you taking any medications for Osteoporosis (Bisphosphonates) like

For women check all that apply:

Have you experienced an unusual reaction to any of the following?

choose all of the following that you may have had in the past or that currently apply to you:

Please list any other medical concerns not listed above:

List all the medication currently taking or have taken within last two years:

Dental Head and Neck:

Are/Were you in Pain?

Are you currently in pain?

Rate of discomfort:

Approximately when did you first notice the condition?

What have you done or happened since:

Medication Taken for the condition in question:

Circle that best describe your discomfort:

Pain to:

Past Dental Experience:

ast root canal Experience:

Level of Dental Anxiety:

By signing this form, I consent Eid Dental Clinic to use and disclose my protected health information to carry out treatment, payment activities and healthcare operations. By signing this form I also understand that it is my responsibility to notify the doctor of any changes in my health/ or medications before any treatment.


Working Hours

Mon-Wed: 9 AM to 6 PM

Thurs: 12 PM to 8 PM

Fri : 10 AM to 3 PM

Sat : 10 AM to 6 PM