Sally A. Abouassaf DDS

9111 FM 723 Suite 400, Richmond, TX, 77406

832-980-9111

Welcome! To assist us in serving you, please complete the following confidential form.
The information provided is important to your dental health

Patient Information

First Name:
MI:
Last Name:
Cell phone:
Birth Date:
If minor, parents’ names:
Social Security#:
Home phone:
City:
Mailing address:
State:
Zip:
Employer:
Occupation:
Spouse's name:
Spouse's employer:
Whom may we thank for referring you to our office?
E‐mail:

Medical Health History

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

Cancer or tumor
Heart Disease
Heart murmur, mitral valve prolapses, heart defect
Rheumatic fever or rheumatic heart disease
Artificial Joint (Knee, Hip… etc.)
High or low blood pressure
Pace maker
Tuberculosis or other lung problems
Kidney disease
Hepatitis or other liver disease
Alcoholism
Blood transfusion
Diabetes
Neurologic condition
Epilepsy, seizures, or fainting spells
Emotional condition
Arthritis
Herpes or cold sores
AIDS or HIV positive
Migraine headaches or frequent headaches
Anemia or blood disorders
Abnormal bleeding after extractions, surgery, or trauma
Hay fever or sinus trouble
Allergies or hives
Asthma
Osteoporosis
Do you smoke or use chewing tobacco?
Have you been diagnosed with sleep apnea?

Are you allergic to, or have you reacted adversely to any of the following?

Latex material
Penicillin or other antibiotics
Local Anesthetics ("Novocain")
Codeine or other narcotics
Sulfa drugs
Aspirin
Barbiturates, sedatives, or sleeping pills
Other:

Are you taking any of the following?

Aspirin
Anticoagulants (blood thinners)
Antibiotics or sulfa drugs
High blood pressure medicine
Antidepressants or tranquilizers
Nitroglycerin
Insulin, Orinase, or other diabetes drug
Cortisone or other steroids
Osteoporosis (bone density) medicine
Bisphosphonates Drugs
Other:

Women:

Expected delivery date:
Name of physician:

Do you have any disease, condition, or a problem not listed above?

Dental Health History


How often do you brush?
How often do you floss?
Chief dental complaint
Last Dental visit

Do you have any jaw symptoms or headaches upon awakening in the morning?
Do you avoid brushing any part of your mouth because of pain?
Does your gum bleed easily?
Does your gum bleed when you floss?
Does your gum feel swollen or tender?
Are you apprehensive about dental treatment?
Have you had problems with previous dental treatment?
Do you gag easily?
Does your jaw make noise so that it bothers you or others?
Do you clench or grind your jaws frequently?
Do your jaws ever feel tired?
Does your jaw get stuck so that you can’t open freely?
Does it hurt when you chew or open wide to take a bite?
Do you have earaches or pain in front of the ears?
Are you unable to open your mouth as far as you want?
Do you have a temporomandibular (jaw) disorder (TMD)?
Have you had a blow to the jaw (trauma)?
Do you wear dentures?
Does food catch between your teeth?
Do you have difficulty in chewing your food?
Do you chew on only one side of your mouth?
Have you ever noticed slow-healing sores I or about your mouth?
Are your teeth sensitive?
Do you take medications or pills for pain or discomfort? (pain relievers, muscle relaxants, antidepressants)

Do you feel twinges of pain when your teeth come in contact with:
Hot foods or liquids?
Cold foods or liquids?
Sours?
Sweets?
Do you have pain in the face, cheeks, jaws, joints, throat, or temples?
Do you take fluoride supplements?
Are you dissatisfied with the appearance of your teeth?
Do you prefer to save your teeth?
Are you interested in whiter teeth?
Are you a habitual gum chewer or pipe smoker?

Signature of patient (or parent):

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Date:

Signature of Dentist:

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Date:

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