Dentistry Patient Form

Do you, or have you ever, had any of the following?

Any breathing or respiratory problems?
Asthma? (If yes answer a,b)
a) If yes are you steroid dependent?
b) Do you use an inhaler?
Sinus Problems?
Seasonal allergies or hayfever?
Airway obstructions?
Difficulty with intubation during general anesthesia?
A smoking habit ?
History of TB?
High blood pressure?
Low blood pressure?
Heart Attack?
Coronary Artery disease?
Rheumatic Fever
Heart murmur?
Inborn heart defects?
Mitral Valve prolapse?
Artificial Heart Valves?
Pacemaker? ( If yes, answer a)
a) Should electronic devices be avoided?
Heart Surgery?
Do you require antibiotics before dental treatment?
Blood dyscrasias?
Sickle Cell anemia?
Thyroid problems?
Diabetes? (If yes answer a-c)
a) If diabetic are you on insulin?
b) If diabetic are you well controlled?
c) If diabetic are you on oral medications?
Liver Disease?
Hepatitis A?
Hepatitis B?
Hepatitis C?
Stomach or duodenal ulcer?
GERD (Gastro Esophageal Reflux Disease)
Kidney disease?
Kidney stones?
Cancer? (If yes please answer a-d)
a) What type of cancer did you have?
b) Chemotherapy?
c) Radiation?
d) Other treatment for cancer?
Facial or Jaw trauma?
Bone, joint or muscular problems?
Artificial joints or surgically placed prosthesis?
Any problems with local anesthesia?
Fainting with local anesthesia?
Allergy to local anesthesia? If so, what happened?
Difficulty getting numb?
History of paresthesia?
Neurological Disorders?
Mental or emotional problems ?
Alcohol or substance abuse?


Are you experiencing pain from your mouth at this time?
Do your gums bleed? When?
Have you ever has an acute sore mouth or "trench" mouth?
Are you aware of a bad taste or odor in your mouth?
Are you troubled with frequent "gum boils"?
Cold Sores?
Oral Herpes?
Xerostomia (dry mouth)?
Did either your mother, father, brother or sister lose all their natural teeth?
Are you satisfied with the appearance of your teeth?
Have you ever had a severe toothache?
Are you bothered by tooth sensitivity? Hot, cold, sweets?
Does food catch between your teeth?
Do tartar and stain return quickly?
Do cavities develop rapidly?
Can you chew satisfactorily?
Do you chew on both sides of your mouth?
Do you have any particular mouth habits? Lip, cheek or tongue biting, foreign objects between teeth, etc.?
Are you conscious of any habit with your tongue?
Do you clench or grind your teeth?
Do you awaken in the morning with your teeth together, tired jaws, numb feeling in your teeth or pain in your jaw?
Do your teeth come together evenly?
Are you conscious of sore, loose or shifting teeth?
Are you conscious of any high or rough teeth or fillings?
Do you ever have pain opening or closing your mouth?
Does your jaw ever go, "out of joint"?
Have you ever had any teeth removed?
Did you have the missing tooth or teeth replaced?


Allergy to latex?
Allergy to nickel, acrylic or other?
Allergic to any medications or foods? (If yes please list)

Female Patients only:

Taking birth control pills?
HIV positive?
Have you had any infections in the last 2 weeks?
Do you have any medical problems not mentioned above? (Please list)

Please list all prescription and non-prescription medications, and herbal products that you are presently taking:


Office Hours

Monday – Friday 8:00 – 5:00
Saturday 9:00 – 5:00
Sunday 11:00 – 4:00


About Dr. Shahrzad Nazari

Dr. Nazari


– Doctor of Dental Surgery (DDS.) Tehran, Iran
– Master of Science (MSc) in Endodontics
– National Board certificate in Endoodnics
– Doctor of Clinical Dentistry (DClinDent) in Endodontics


– Member of Iranian medical council
– Member of Iranian Dental Association
– Member of Iranian association of Endodontists (IAE)
– Member of Australian Dental Association (ADA)
– Member of Australian Society of Endodontology (ASE)
– Member of American Association of Endodontists (AAE)
– Member of International Association of Dental Traumatology(IADT)
– Member of Royal Australasian College of Dental Surgeons (RACDS) in Specialist Practice of Endodontics.