Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is an essential 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.

Please fill out the form below. If you have trouble filling out this form online, please email beth@maestridental.com to send you a printable version of the form to fill out and bring with you to your next appointment.

* Required


                        First Name* 
Last Name* 
Email*
                            
                        
Patient First Name - If different 
Patient Last Name - If different 
Date of Birth*
                            
                            MM slash DD slash YYYY
                        
                        
Are you under a physician's care now?
			
				
				Yes
			
			
				
				No
			
If yes, please explain:
Have you ever been hospitalized or had a major operation?
			
				
				Yes
			
			
				
				No
			
If yes, please explain the operation or procedure.
Have you ever had a serious head or neck injury?
			
				
				Yes
			
			
				
				No
			
If yes, please explain injury below.
Please list any other serious illness you have ever had.
Are you taking any medications, pills, or drugs?*
			
				
				Yes
			
			
				
				No
			
Are you on a special diet?*
			
				
				Yes
			
			
				
				No
			
Do you use tobacco?*
			
				
				Yes
			
			
				
				No
			
Do you use controlled substances?*
			
				
				Yes
			
			
				
				No
			
Are you pregnant/Trying to get pregnant? Taking Oral Contraceptives? Nursing?*
			
				
				Yes
			
			
				
				No
			
If yes, to any of the questions directly above, please indicate which one applies to you and which medications you are taking, if applicable.
Are you allergic to any of the following?*
								
								Asprin
							

								
								Penicillin
							

								
								Codeine
							

								
								Local Anesthetics
							

								
								Acrylic
							

								
								Metal
							

								
								Latex
							

								
								Sulfa drugs
							

								
								N/A
							
Please list any other allergies.
Do you take, or have taken, Phen-Fen or Redux?
			
				
				Phen-Fen
			
			
				
				Redux
			
			
				
				Both
			
			
				
				No
			
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
			
				
				Yes
			
			
				
				No
			
Have you been affected or diagnosed by any of the following?*
								
								Aids/HIV Positive
							

								
								Alzheimer's Disease
							

								
								Anaphyllaxis
							

								
								Anemia
							

								
								Angina
							

								
								Arthritis/Gout
							

								
								Artificial Heart Valve
							

								
								Artificial Joint
							

								
								Asthma
							

								
								Blood Disease
							

								
								Blood Transfusion
							

								
								Breathing Problem
							

								
								Bruise Easily
							

								
								Cancer
							

								
								Chemotherapy
							

								
								Chest Pains
							

								
								Cold sores/fever blisters
							

								
								Congenital Heart Disorder
							

								
								Convulsions
							

								
								Cortisone Medicine
							

								
								Diabetes
							

								
								Drug Addiction
							

								
								Easily Winded
							

								
								Emphysema
							

								
								Epilepsy or Seizures
							

								
								Excessive Bleeding
							

								
								Excessive Thirst
							

								
								Fainting Spells/Dizziness
							

								
								Frequent Cough
							

								
								Frequent Diarrhea
							

								
								Frequent Headaches
							

								
								Genital Herpes
							

								
								Glaucoma
							

								
								Hay Fever
							

								
								Heart Attack/Failure
							

								
								Heart Murmur
							

								
								Heart Pacemaker
							

								
								Heart Trouble/Disease
							

								
								Hemophilia
							

								
								Hepatitis A
							

								
								Hepatitis B or C
							

								
								Herpes
							

								
								High Blood Pressure
							

								
								High Cholesterol
							

								
								Hives or Rash
							

								
								Hypoglycemia
							

								
								Irregular Heartbeat
							

								
								Kidney Problems
							

								
								Leukemia
							

								
								Liver Disease
							

								
								Low Blood Pressure
							

								
								Lung Disease
							

								
								Mitral Valve Prolapse
							

								
								Osteoporosis
							

								
								Pain in Jaw Joints
							

								
								Parathyroid Disease
							

								
								Psychiatric Care
							

								
								Radiation Treatments
							

								
								Recent Weight Loss
							

								
								Renal Dialysis
							

								
								Rheumatic Fever
							

								
								Rheumatism
							

								
								Scarlet Fever
							

								
								Shingles
							

								
								Sickle Cell Disease
							

								
								Sinus Trouble
							

								
								Spina Bifida
							

								
								Stomach/Intestinal Disease
							

								
								Stroke
							

								
								Swelling of Limbs
							

								
								Thyroid Disease
							

								
								Tonsillitis
							

								
								Tuberculosis
							

								
								Tumors or Growths
							

								
								Ulcers
							

								
								Veneral Disease
							

								
								Yellow Jaundice
							

								
								N/A
							
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welcome

Welcome to exceptional family dentistry in Lafayette. Dr. Gina Liggio Maestri DDS and her team of dedicated dental professionals are here to provide you and your family with a level of caring clinical excellence you’ve never experienced before. From our state-of-the-art technology to our many comfort amenities, we have everything you need to feel relaxed while you enjoy gentle dentistry in Acadiana.

find us @

1601 Kaliste Saloom Rd
Lafayette, LA 70508

337-704-2126

SCHEDULE AN APPOINTMENT

GET DIRECTIONS

EMAIL US

find us @

1601 Kaliste Saloom Road
Lafayette, LA 70508

337-704-2126

SCHEDULE AN APPOINTMENT

GET DIRECTIONS

EMAIL US

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