Oral Surgery and Dental Implant Center
Call 408-946-6666 to make an appointment
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Services
Dental Implant
Bone Grafting
Wisdom Teeth
Facial Trauma
Tooth Extractions
Pre-Prosthetic Surgery
Oral Pathology
TMJ Disorders
Impacted Canines
Anesthesia
Surgical Instructions
Before Anesthesia
Wisdom Tooth Removal
Dental Implant Surgery
Exposure of an Impacted Tooth
Extractions
Patient Information
First Visit
Patient Registration
Doctor Referral
Insurance
Financial Policy
Meet Us
Meet Dr. Nguyen
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Patient Information
Mr.
Mrs.
Ms.
Dr.
*
First Name
*
Last Name
Gender
Male
Female
*
Birthday
*
Email
*
Street
*
City
*
State
*
Zip
*
Home Phone
*
Cell
Are you a new patient?
Yes
No
*
Your Primary Dentist
Your Primary Doctor
Referred by
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Reasons for today visit
How will you pay for the service?
Cash
Check
Credit Card
Is your dental insurance either PPO or HMO?
Yes
No
Who will pay for the service?*
Mother
Father
Self
Spouse
Other
*
In case of emergency who should we contact?
*
Emergency Person Phone
Relationship
Dental Insurance Information
Employer
Plan Name
Insurance Name
Address
City
State
Zip
Phone
Policy I.D. Number
Group Number
Group Name
Insured First Name
Insured Last Name
Relation to the patient
Birth Date
Insured Person Address
City
State
Zip
Phone
Medical Insurance Information
Plan Name
Insurance Name
Phone
Policy I.D. Number
Group Number
Group Name
Insured First Name
Insured Last Name
Relation to the patient
Birth Date
Insured Person Address
City
State
Zip
Phone
Health History
*
Your weight
*
Your height
Has anything happened to your health?
No
Yes
Do you currently have any physician care?
No
Yes
Have you had any illness, surgeries or been hospitalized in the past five years?
No
Yes
Do you have any implant?
No
Yes
Have you ever had a heart valve replacement or vascular graft?
No
Yes
Have you ever had any strange reactions to anesthesia?
No
Yes
Do you need to take any antibiotics before dental treatment?
No
Yes
Is there any health concerns that doctor should know about?
No
Yes
Is there anything you should tell doctor before the treatment?
No
Yes
Rheumatic fever
No
Yes
Damaged heart valves?
No
Yes
Heart murmur?
No
Yes
High blood pressure?
No
Yes
Low blood sugar?
No
Yes
Kidney problem?
No
Yes
High cholesterol?
No
Yes
Are you on dialysis?
No
Yes
Arthritis or joint disease?
No
Yes
Osteoporosis
No
Yes
Osteonecrosis
No
Yes
Stomach ulcers
No
Yes
Contagious diseases
No
Yes
Sexually transmitted disease
No
Yes
Immune system issues?
No
Yes
Healing delay
No
Yes
Tumors?
No
Yes
Cancer, Radiation Therapy or Chemotherapy
No
Yes
Chronic fatigue
No
Yes
Alcoholic problem?
No
Yes
Drug problems?
No
Yes
Are you wearing any contact lenses?
No
Yes
Eye diseases?
No
Yes
Depression or anxiety?
No
Yes
Removable dental appliance?
No
Yes
Jaws pain when eating?
No
Yes
Stroke
No
Yes
Thyroid trouble
No
Yes
Diabetes
No
Yes
Low blood pressure
No
Yes
Chest pain
No
Yes
Heart attack
No
Yes
Irregular heart beat
No
Yes
Cardiac pacemaker
No
Yes
Heart surgery
No
Yes
Pneumonia, Bronchitis or Chronic Cough
No
Yes
Asthma
No
Yes
Hay fever / sinus problems
No
Yes
Snoring / sleep apnea
No
Yes
Difficult breathing or lung problem?
No
Yes
Tuberculosis
No
Yes
Emphysema
No
Yes
Do you smoke?
No
Yes
Do you use chewing tobacco?
No
Yes
Blood transfusion
No
Yes
Blood disorder
No
Yes
Bruises?
No
Yes
Bleeding tendency / abnormal bleed
No
Yes
Hepatitis, jaundice, or liver disease
No
Yes
Infectious mononucleosis
No
Yes
Gallbladder problems?
No
Yes
Faint
No
Yes
Convulsions or epilepsy
No
Yes
Does anyone in your family have a history of cancer?
No
Yes
Does anyone in your family have a history of diabetes?
No
Yes
Does anyone in your family have a history of heart disease?
No
Yes
Does anyone in your family have a history of anesthetic problems?
No
Yes
Are you on any medications?
No
Yes
Are you now taking Blood thinners?
No
Yes
Have you ever taken tranquilizers, sleeping pills, anti depressants and/or narcotics on a regular basis?
No
Yes
Are you taking Aspirin?
No
Yes
Are you taking Amoxicillin?
No
Yes
Any narcotics?
No
Yes
Other medications?
No
Yes
*
Please list any known allergies
*
List of current medications
*
Ever taken any bone density bone medications like Fosamax, Boniva, Actonel? If yes, how long?
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Date:
January 9, 2025
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