Daryl E. Malena DDS
10838 Old Mill Road, Suite 8
Omaha, Nebraska 68154
(402) 330-4100     (800) 825-4867   fax (402) 330-4103

Name______________________________________    Date of birth___________   Age_____
Sex_____________   Height   _____________________   Weight   ______________________

Name of your dentist(s):_________________________________________________________
Name of your physician(s): ______________________________________________________
___________________________________________________________________________

Are you currently under treatment for any medical condition?
___________________________________________________________________________
List all medications including aspirin, vitamins and natural supplements:_______________________
___________________________________________________________________________
For your convenience, we can make a photocopy if you carry a list of medications.

Have you ever had a reactions to:  Aspirin   Codeine   Epinephrine   Latex   Penicillin   Local Anesthetic
Any other known allergies:________________________________________________________
Have you ever been told to take an antibiotic before having your dental work?   ________________

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

  Emphysema (you, a sibling or a parent)            Diabetes (you, a sibling or a parent)

Do you smoke?______  How long?______   Use other tobacco products?_______________

Have you ever had gum treatment?____________________  Orthodontics?______________ 

Do you think dental treatment makes you more anxious than it does other people?___________

Are you having pain at this time?_______   Sensitivity?_______   Bad breath?______________

Signature________________________________________   Date_____________

Please do not email this form to the office.  Instead, bring it to your first appointment.  

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