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520-293-2166
5828 N Oracle Rd, Suite #100, Tucson, AZ 85704
520-293-2166
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520-293-2166
About
Meet Dr. Pandhi
Blog
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Services
Preventative Dentistry
Dental Exams and Cleanings
Dental Sealants
Restorative Dentistry
Dental Filling
Dental Crowns
Dentures
Dental Implants
Dental Extractions
Root Canals
Cosmetic Dentistry
Dental Bonding
Dental Veneers
Teeth Whitening
Other Services
Dental House Calls
Family Dentist
Sleep Apnea Therapy & Mouth Guards
Patients
Before & Afters
First Visit
Patient Forms
Payments & Insurance
Reviews
Contact
About
Meet Dr. Pandhi
Blog
Tour Our Office
Services
Preventative Dentistry
Dental Exams and Cleanings
Dental Sealants
Restorative Dentistry
Dental Filling
Dental Crowns
Dentures
Dental Implants
Dental Extractions
Root Canals
Cosmetic Dentistry
Dental Bonding
Dental Veneers
Teeth Whitening
Other Services
Dental House Calls
Family Dentist
Sleep Apnea Therapy & Mouth Guards
Patients
Before & Afters
First Visit
Patient Forms
Payments & Insurance
Reviews
Contact
About
Meet Dr. Pandhi
Tour Our Office
Blog
Services
Preventive Dentistry
Dental Exams and Cleanings
Dental Sealants
Restorative Dentistry
Dental Bridges
Dental Crowns
Dental Extractions
Dental Filling
Dental Implants
Dentures
Root Canals
Cosmetic Dentistry
Clear Aligners
Dental Bonding
Dental Veneers
Full Mouth Reconstruction
Myofunctional Orthodontics
Teeth Whitening
Other Services
At-Home Sleep Studies
Dental House Calls
Sleep Apnea Therapy & Mouth Guards
Patients
Before & Afters
First Visit
Patient Forms
Payments & Insurance
Reviews
Contact
Patient Medical History
Patient Information
Patients Name
Todays Date
MM slash DD slash YYYY
Date of Last Visit
MM slash DD slash YYYY
Date of Med. History
MM slash DD slash YYYY
Address
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Email
Marital Status
Birth Date
MM slash DD slash YYYY
Physician Name
Physician Phone
Pharmacy
Pharmacy Phone
Medical Information
Sex
Male
Female
Are you taking Birth Control Pills?
Yes
No
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
If pregnant, # of weeks
Do you smoke or use tobacco?
Yes
No
Height
Weight
Do you have the following medical conditions?
Artificial Joints
(Required)
Yes
No
Abnormal Bleeding
(Required)
Yes
No
Alcohol Abuse
(Required)
Yes
No
Anemia
(Required)
Yes
No
Arthritis
(Required)
Yes
No
Artificial Heart Valve
(Required)
Yes
No
Asthma
(Required)
Yes
No
Blood Transfusion
(Required)
Yes
No
Cancer
(Required)
Yes
No
Chemo/Radiation TX
(Required)
Yes
No
Chicken Pox
(Required)
Yes
No
Colitis
(Required)
Yes
No
Congenital Heart Defect
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Difficulty Breathing
(Required)
Yes
No
Drug Abuse
(Required)
Yes
No
Emphysema
(Required)
Yes
No
Epilepsy
(Required)
Yes
No
Fainting Spells
(Required)
Yes
No
Fever Blisters
(Required)
Yes
No
Frequent Headaches
(Required)
Yes
No
Glaucoma
(Required)
Yes
No
Heart Murmur
(Required)
Yes
No
HIV / AIDS
(Required)
Yes
No
Hay Fever
(Required)
Yes
No
Heart Attack
(Required)
Yes
No
Heart Surgery
(Required)
Yes
No
Hemophilia
(Required)
Yes
No
Hepatitis A
(Required)
Yes
No
Hepatitis B
(Required)
Yes
No
High Blood Pressure
(Required)
Yes
No
Kidney Problems
(Required)
Yes
No
Liver Disease
(Required)
Yes
No
Low Blood Pressure
(Required)
Yes
No
Lupus
(Required)
Yes
No
Mitral Valve Prolapse
(Required)
Yes
No
Pace Maker
(Required)
Yes
No
Psychiatric Problems
(Required)
Yes
No
Rheumatic Fever
(Required)
Yes
No
Scarlet Fever
(Required)
Yes
No
Seizures
(Required)
Yes
No
Shingles
(Required)
Yes
No
Sickle Cell Disease
(Required)
Yes
No
Sinus Problems
(Required)
Yes
No
Stroke
(Required)
Yes
No
Thyroid Problems
(Required)
Yes
No
Tuberculosis
(Required)
Yes
No
Ulcers
(Required)
Yes
No
Venereal Disease
(Required)
Yes
No
Yellow Jaundice
(Required)
Yes
No
Do you have the following allergies?
Aspirin
(Required)
Yes
No
Codeine
(Required)
Yes
No
Dental Anesthetics
(Required)
Yes
No
Erythromycin
(Required)
Yes
No
Jewelry
(Required)
Yes
No
Latex
(Required)
Yes
No
Metals
(Required)
Yes
No
Penicillin
(Required)
Yes
No
Tetracycline
(Required)
Yes
No
Other Allergies
Do you take any medication?
(Required)
Yes
No
Medications (No dosage required)
Is there any disease, condition, or problem that you think this office should know about that is not covered above?
Yes
No
Please describe disease, condition, or problem
Additional Notes
Signature
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