Syracuse Family Dental Clinic LLC
Dr. Michael L. Gailey, DDS, MS
Today’s Date: ________________ Patient Name: ____________________________________
Medical Physician’s Name: ____________________ Gender: M F Date of Birth: __________
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.
Are you under a physician’s care now? Yes No If yes, explain ______________________________
Have you ever been hospitalized or had a major operation? Yes No
If yes, explain__________________________________________________________________________
Have you ever had a serious head or neck injury? Yes No
If yes, explain__________________________________________________________________________
Are you taking any medications, pill, or drugs? Yes No If yes, explain ________________________
Are you currently taking medication for or have you been diagnosed with osteoporosis? Yes No
Do you use tobacco? Yes No
Are you on a special diet? Yes No
Do you use controlled substances? Yes No
WOMEN: Are you: Pregnant/trying to get pregnant? Nursing? Taking oral contraceptives?
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic Metal Latex Local anesthetics
Other _____________________
Do you have or have you had any of the following?
AIDS/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve*
Artificial Joint*
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
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 Pace Maker*
Heart Trouble/Disease
Hemophilia
Renal Dialysis
Hepatitis A
Rheumatic Fever*
Hepatitis B or C
Rheumatism
Herpes
Scarlet Fever
High Blood Pressure
Shingles
Hives or Rash
Sickle Cell Disease
Hypoglycemia
Sinus Trouble
Irregular Heartbeat
Spina Bifida
Kidney Problems
Stomach/Intestinal Disease
Leukemia
Stroke
Liver Disease
Swelling of Limbs
Low Blood Pressure
Thyroid Disease
Lung Disease
Tonsilitis
Mitral Valve Prolapse* Tuberculosis
Pain in Jaw Joints
Tumors or Growths
Parathyroid Disease
Ulcers
Psychiatric Care
Venereal Disease
Radiation Treatments
Yellow Jaundice
Recent Weight Loss
*Condition may require medication
Have you ever had any serious illness not listed above? Yes No
N/A _________________
Comments:_____________________________________________________________________________
______________________________________________________________________________________
I authorize Syracuse Family Dental Clinic LLC and /or such associates or assistants as
designated to perform those procedures as may be deemed necessary or advisable to maintain my
dental health or the dental health of any minor or other individual for which I have responsibility
including arrangement and/or other pharmaceutical agent(s), including those related to
restorative, palliative, therapeutic or surgical treatments.
I understand that the administration of local anesthetic may cause an untoward reaction or
side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation,
temporary or rarely, permanent numbness, and muscle soreness. I understand that occasionally
needles break and may require surgical retrieval.
I understand that as a part of dental treatment, including preventive procedures such as
cleaning and basic dentistry, including fillings of all types, teeth may remain sensitive or even
possibly quite painful both during and after completion of treatment. Gums and surrounding
tissues may also be sensitive or painful during and/or after treatment.
I voluntarily assume any and all possible risks, including the risk of substantial and
serious harm, if any, which may be associated with general preventative and operative treatment
procedures in hopes of obtaining the potential desired results, which may or may not be achieved,
for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and
purpose of the foregoing procedures have been explained to me if necessary and I have been
given the opportunity to ask questions.
Signature:______________________________________________Date:___________________________
(Patient, legal guardian or authorized agent of patient)
Witness:_______________________________________________Date:____________________________
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