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Patient History and Acquaintance

Jonathan Golab DDS - Providing services in dentistry to the areas of Flower Mound, Northern Texas (TX).

Please note that it is important to fill in all the fields before submitting. Thank you.

About you

Title :

MrMrsMsDr

*Last name :

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*Your birthday :

Age:

Sex : MaleFemale

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*Residence address :

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*Email address :

Marital Status : SingleMarriedPartneredDivorced/SeparatedWidowed

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How long there ?

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Where & when are best times to reach you? Have you visited our website? YesNo

How did you hear about us?

Whom may we Thank for referring you?

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Previous dentist :

Present dentist :

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Spouse information

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Emergency contact information for patient in case of an emergency
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Insurance information

Primary insurance

Dental coverage?

YesNo

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Secondary insurance

Dental coverage?

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Medical History

IF ALL ANSWERS ARE NO CLICK HERE

Do you have a personal physician?

YesNo

Physician’s Name :

Telephone home :

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Date of last visit :

Your current physical health is :

GoodFairPoor

Are you taking any medications at this time?

YesNo

Has there been any change in your general health during the last year?

YesNo

Have you been examined or treated by your physician within the last year?

YesNo

Do you smoke or use tobacco in any other form?

YesNo

Do you take aspirin on a regular basis?

YesNo

Have you ever had a serious illness or operation?

YesNo

Did you have a blood transfusion from 1980 to 1985?

YesNo

Have you been under treatment with either Fen-Phen or Redux?

YesNo

Have you ever had excessive bleeding following extraction of teeth or from a cut?

YesNo

Have you ever had severe pains of the face or head?

YesNo

Do you wear a cardiac pacemaker, or have you had heart surgery?

YesNo

Are you required to take any medication before your dental visit?

YesNo

For women :

Are you using a prescribed method of birth control? YesNo

Are you pregnant? YesNo Week # :

Are you nursing? YesNo

Have you ever had any of the following diseases or medical problems IF ALL ANSWERS ARE NO CLICK HERE

YesNo	Abnormal Bleeding / Hemophilia
YesNo	AIDS related complex
YesNo	Alcohol / Drug abuse
YesNo	Anemia
YesNo	Arthritis, Rheumatism
YesNo	Artificial bones / Joints / Valves
YesNo	Asthma
YesNo	Chemotherapy (Center, leukemia)
YesNo	Colitis
YesNo	Congenital heart defect
YesNo	Diabetes(Sugar Disease)
YesNo	Difficulty breathing
YesNo	Emphysema
YesNo	Epilepsy / seizures
YesNo	Excessive bleeding
YesNo	Respiratory disease
YesNo	Artifical prosthesis
YesNo	Congenital heart disease
YesNo	X-Ray or cobalt treatment
YesNo	Chest Pain Upon Exertion
YesNo	Shortness of Breath
YesNo	Ulcers of the Stomach

YesNo	Fainting spells / seizures
YesNo	Frequent headaches
YesNo	Eye Disorders, Glaucoma
YesNo	Hayfever
YesNo	Heart attack / Surgery
YesNo	Heart murmur
YesNo	Hepatitis / jaundice
YesNo	Herpes / Fever blisters
YesNo	High blood pressure
YesNo	Allergies or Hives
YesNo	Hospitalized for any reason
YesNo	Kidney or Bladder Disorders
YesNo	Liver disease
YesNo	Lupus
YesNo	Angina pectoris
YesNo	Cerebral palsy
YesNo	Joint replacement
YesNo	Nervous disorder
YesNo	Tumors or growths
YesNo	Prosthetic Implant (i.e. hip pin)
YesNo	Venereal Disease

YesNo	Mitral valve prolapse
YesNo	Pacemaker
YesNo	Psychiatric treatment
YesNo	Radiation treatment
YesNo	Rheumatic / Scarlet fever
YesNo	Shingles
YesNo	Sickle cell disease / Traits
YesNo	Sinus problems
YesNo	Stroke
YesNo	Thyroid problems
YesNo	Tuberculosis (TB)
YesNo	Ulcers
YesNo	Tonsillitis
YesNo	Head injuries
YesNo	Heart failure
YesNo	Chicken pox
YesNo	Sinus Trouble
YesNo	Blood disease
YesNo	Drug addiction
YesNo	Psychiatric Treatment
YesNo	STD

Are you allergic to any of the following? IF ALL ANSWERS ARE NO CLICK HERE

YesNo	Aspirin
YesNo	Penicillin
YesNo	Jewelry / Metals
YesNo	Anesthetic (Novocain, ETC))

YesNo	Dental anesthetics
YesNo	Other
YesNo	Erythromycin
YesNo	Sulfa Drugs

YesNo	Codeine
YesNo	Tetracycline
YesNo	Latex

Please list any other drugs / Materials that you are allergic to :

Dental history

IF ALL ANSWERS ARE NO CLICK HERE
How long since your last dental visit?
Are you having any dental problems presently?	YesNo	If so, describe :
Are you currently in pain?	YesNo
Your current dental health is : GoodFairPoor
Do you floss your teeth regularly?	YesNo
Do you brush your teeth regularly?	YesNo
Type of bristles on your toothbrush? HardMediumSoft
Have you ever had gum treatment?	YesNo
Do your gums ever bleed?	YesNo
Have you ever had periodontal (gum) treatments?	YesNo
Are you interested in cosmetic dentistry (bleaching, etc.)?	YesNo
Have you ever had orthodontics (braces)?	YesNo
Do you grind or clench your teeth when you are nervous or sleeping?	YesNo
Do your jaws click or pop when you chew?	YesNo
Have you ever been treated for TMJ (jaw) problems?	YesNo
Do you have any loose teeth?	YesNo
Do you still have wisdom teeth?	YesNo
Would you like fresher breath?	YesNo
Is there any other information we should know about your health or previous dental visits? YesNo
If so, explain :


	* I authorize the release of all dental information about me or my minor children to Physicians, Hospitals, Insurance companies and Dentists.

*Signature :

Date :

Jonathan J. Golab, D.D.S., P.A.
| 855.691.8133

Jonathan J.Golab, DDS 4.9 out of 5 based on 50 Google reviews.

JONATHAN J. GOLAB, D.D.S., P.A Located at 3020 Broadmoor Lane #100, Flower Mound, texas 75022 . Phone: 855-691-8133. www.drgolab.net.