Los Angeles Office Patient Forms

Los Angeles Office Patient Forms

Los Angeles Office Patient Forms

At Miracle Smile Dentistry, we offer patient forms online so you can complete them in the convenience of your own home or office. You may email us the completed forms or bring them with you on your next visit.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.

  • Download the necessary form(s), print it out and fill in the required information.


Do you have any of the following diseases or problem
( Check DK if you Don't Know the answer to the question )

Active Tuberculosis

Persistent cough greater than a 3 week duration

Cough that produces blood

Been exposed to anyone with tuberculosis

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information

Do your gums bleed when you brush or floss?

Are your teeth sensitive to cold, hot, sweets or pressure?

Does food or floss catch between your teeth?

Is your mouth dry?

Have you had periodontal (gum) treatments?

Have you ever had orthdontic (braces) treatment?

Have you had any problems associated with previous dental treatment?

Are you currently experiencing dental pain or discomfort?

Do you have earaches or neck pains?

Do you have any clicking, popping or discomfort in the jaw?

Do you brux or grind your teeth?

Do you have sores or ulcers in your mouth?

Do you wear dentures or partials?

Do you participate in active recreational activities?

Have you ever had a serious injury to your head or mouth?

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.

Medical Information

Are you under a physician's care now?

Have you ever been hospitalized or had a major operation?

Have you ever had a serious head or neck injury?

Are you taking any medications, pills, or drugs?

Do you take, or have you taken, Phen-Fen or Redux?

Do you need to pre-medicate?

Are you on a special diet?

Do you use tobacco?

Do you use controlled substances?

Are you allergic to any of the following? (Check all that apply)

Women: Are you Pregnant/Trying to get pregnant?

Taking oral contraceptives?


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/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

  • Hepatitis A

  • Hepatitis B or C

  • Herpes

  • High Blood Pressure

  • Hives or Rash

  • Hypoglycemia

  • Irregular Heartbeat

  • Kidney Problems

  • Leukemia

  • Liver Disease

  • Low Blood Pressure

  • Lung Disease

  • Mitral Valve Prolapse

  • Pain in Jaw Joints

  • Parathyroid Disease

  • Psychiatric Care

  • Radiation Treatment

  • Recent Weight Loss

  • Renal Dialysis

  • Rheumatic Fever

  • Rheumatism

  • Scarlet Fever

  • Shingles

  • Sickle Cell Disease

  • Sinus Trouble

  • Spina Bifida

  • Stomach / Intestinal Disease

  • Stroke

  • Swelling of Limbs

  • Thyroid Disease

  • Tonsillitis

  • Tuberculosis

  • Tumors or Growths

  • Ulcers

  • Venereal Disease

  • Yellow Jaundice

Have you ever had any serious illness not listed above?

Note: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

3103229000 https://www.miraclesmiledentistry.com/schedule-an-appointment.html