Ron D. Thoman, D.D.S
Diplomate American Board of Oral and Maxillofacial Surgery
Ryan Hambleton DMD
719-590-1500 Oral and Maxillofacial Surgery Specialists, P.C.

Demographic and Health History

Please fill out and submit the following forms prior to your first scheduled appointment.

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Last Name First Name Middle Name   Title
Email Date of Birth
Telephone Cell Phone
Residence Address
City State Zip
Occupation Employer/School Work Phone



Parent/Guardian (if minor) Home Phone Number
Address
Occupation Employer/School Work Phone



INSURANCE INFORMATION:

Dental: Insurance Co. Subscriber
 
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Secondary Dental: Insurance Co. Subscriber
 
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Medical: Insurance Co. Subscriber
 
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Secondary Medical: Insurance Co. Subscriber
 
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Employer



IN CASE OF EMERGENCY:

Name Relationship
Address Home Phone #:
City Zip Work Phone #:

Name of person or doctor who referred you to this office

Have you or has any member of your family ever been a patient in our
office prior to today?
If yes, name of patient and approximate date of treatment:



MEDICAL AND DENTAL HISTORY

Physicians Name: Date of Last Physical Exam:
Present Complaint or Problem (max 150 characters):
HEART PROBLEMS Yes No
MURMUR/VALVULAR DEFECTS Yes No
RHEUMATIC FEVER Yes No
CONGENITAL HEART DISEASE Yes No
HEART ATTACK Yes No
CHEST PAIN Yes No
HIGH BLOOD PRESSURE Yes No
FREQUENTLY SWOLLEN ANKLES Yes No
SHORTNESS OF BREATH Yes No
LUNG DISEASE/PERSISTENT COUGH Yes No
PNEUMONIA Yes No
SMOKE OR CHEW TOBACCO Yes No
ALCOHOL OR RECREATIONAL DRUGS Yes No
ASTHMA, HAY FEVER OR ALLERGIES Yes No
STROKE OR TIA Yes No
THYROID DISEASE Yes No
FREQUENT SORES IN MOUTH Yes No
GLAUCOMA Yes No
FAINTING SPELLS Yes No
EPILEPSY, CONVULSIONS, SEIZURES Yes No
DIABETES Yes No
LIVER DISEASE (HEPATITIS /JAUNDICE/CIRRHOSIS) Yes No
KIDNEY DISEASE Yes No
STOMACH ULCER/GASTRO/ESOPHAGEAL REFLUX Yes No
VENEREAL DISEASE Yes No
BLEEDING PROBLEMS/ANEMIA/BLOOD THINNER
BRUISING
Yes No
ARTHRITIS Yes No
REACTION TO ANESTHESIA (ANY RELATIVES) Yes No
RADIATION THERAPY Yes No
MALIGNANCIES Yes No
ARE YOU PREGNANT/BREAST FEEDING Yes No
DO YOU WEAR CONTACT LENSES Yes No
SINUS OR NASAL PROBLEM Yes No
DO YOU PLAY A WIND INSTRUMENT Yes No


Are you allergic to latex(rubber gloves, balloons, elastic)?
Yes No
Have you ever been hospitalized or had previous surgeries?
Yes No
If yes, explain
Are you allergic to or had a reaction to drugs/medications (penicillin, sulfa)?
Yes No
If yes, explain
Are you taking any pills, medications, herbal and/or dietary supplements
Yes No
If so, please list here
Are you taking or have you taken Fosamax, Prolia, Xgeva, Zometa, Boniva, Actonel, Reclast or Prolia?
Yes No
Are you in Good Health?
Yes No
Have there been any changes in your health in the past year?
Yes No
Do you smoke, use recreational drugs or Marijuana?
Yes No
Please describe any current medical treatment, impending operations or any other medical or dental information not noted above that my possibly affect your treatment: (150 char max)
Dentist Name:
Date of last dental exam:
Any previous complications with dental treatment?
Yes No
If yes, explain
Do you clench or grind your teeth?
Yes No
Any pain in or around the ears?
Yes No
Does your jaw pop, click or grind?
Yes No
If so, please describe
Additional comments (200 character max)



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