(740)-548-1800

Same Day Emergency Appointments

Office Hours:
Mon - 8:00am - 5:00pm
Tue - 8:00am - 5:00pm
Wed - 10:00am - 7:00pm

Thur - 8:00am - 3:00pm
Fri - 9:00am - 1:00pm
Second Sat of every month:
8:00am - 1:00pm

Kyle D. Bogan, DDS
7420 Gooding Blvd. Suite 200
Delaware, OH. 43015
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New Patient

Minor Child

Single

Married

Divorced

Widowed

Person Responsible for Account

Dental Insurance

Secondary Insurance

Yes

Emergency Information

Medical History

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.

Yes

Are you under a physician's care now?

Yes

Have you ever been hospitalized or had a major operation?

Yes

Have you ever had a serious head or neck injury?

Yes

Are you taking any medications, pills, or drugs?

Yes

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

Yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes

Are you on a special diet?

Yes

Do you use tobacco?

Yes

Do you use controlled substances?

Women: Are you

Pregnant/Trying to get Pregnant?

Yes

Taking Oral Contraceptives?

Yes

Nursing?

Yes

Are you allergic to any of the following?

Aspirin

Penicillin

Codeine

Local Anesthetics

Acrylic

Metal

Latex

Sulfa drugs

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

AIDS/HIV Positive

Diabetes

Hepatitis B or C

Rheumatic Fever

Alzheimer's Disease

Drug Addiction

Herpes

Rheumatism

Anaphylaxis

Easily Winded

High Blood Pressure

Scarlet Fever

Anemia

Emphysema

High Cholesterol

Shingles

Angina

Epilepsy or Seizures

Hives or Rash

Sickle Cell Disease

Arthritis/Gout

Excessive Bleeding

Hypoglycemia

Sinus Trouble

Artificial Heart Valve

Excessive Thirst

Irregular Heartbeat

Spina Bifida

Artificial Joint

Fainting Spells/Dizziness

Kidney Problems

Stomach/Intestinal Disease

Asthma

Frequent Cough

Leukemia

Stroke

Blood Disease

Frequent Diarrhea

Liver Disease

Swelling of Limbs

Blood Transfusion

Frequent Headaches

Low Blood Pressure

Thyroid Disease

Breathing Problem

Genital Herpes

Lung Disease

Tonsillitis

Bruise Easily

Glaucoma

Mitral Valve Prolapse

Tuberculosis

Cancer

Hay Fever

Osteoporosis

Tumors or Growths

Chemotherapy

Heart Attack/Failure

Pain in Jaw Joints

Ulcers

Chest Pains

Heart Murmur

Parathyroid Disease

Venereal Disease

Cold Sores/Fever Blisters

Heart Pacemaker

Psychiatric Care

Yellow Jaundice

Congenital Heart Disorder

Heart Trouble/Disease

Radiation Treatments

Convulsions

Hemophilia

Recent Weight Loss

Cortisone Medicine

Hepatitis A

Renal Dialysis

Have you ever had any serious illness not listed above?

Yes

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To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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