Full Name(Last, First, Middle Initial):

Email Address:


Are you under a physician's care now?
Yes
No
N/A

Have you ever been hospitalized or had a major operation?
Yes
No
N/A

Have you ever had a serious head or neck injury?
Yes
No
N/A

Are you taking any medications, pills, or drugs?
Yes
No
N/A

Do you take, or have you taken, Phen-Fen or Redux?
Yes
No
N/A

Are you on a special diet?
Yes
No
N/A

Women: Are you pregnant or trying to get pregnant?
Yes
No
N/A

Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Metal
Latex
Local Anesthetics
Other

If you have other allergies please explain:


Do you have, or have you had, any of the following? Please check any that apply.
Aids/HIV Positive
Alzheimer's Disease
Anaphylaxis
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 Disease
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
Hey Fever
Heart Attack/Failure
Heart Murmur*
Heart Pace Maker*
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse*
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


Have you ever had any serious illness not listed above?
Yes
No
N/A

Additional Comments:


Verification Code
(case sensitive):


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.

*Conditions may require medication. N/A - Not Applicable to patient.