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:____________________________