MEDICAL HISTORY

    Patient

    Are you currently under the care of a physician?

    Have you ever had any serious illnesses or operations?

    YesNo

    Have you ever taken Bisphosphonates (IV or Oral)? If yes, please list type and dates taken

    Have you ever had head or neck radiation therapy?

    YesNo

    Are you taking any blood thinners? If yes, which one(s)

    List all medications you are taking:

    Are you allergic to:

    PenicillinClindamycinSulfa DrugsCodeineLatex

    Women Only

    Are you pregnant?

    YesNo

    Nursing?

    YesNo

    Taking Birth Control

    YesNo

    Please check if you have/had:

    Allergies, hay fever, sinusitis

    YesNo

    Emphysema

    YesNo

    Pacemaker

    YesNo

    Anemia

    YesNo

    Epilepsy

    YesNo

    Respiratory disease

    YesNo

    Arthritis, Rheumatism

    YesNo

    Fainting

    YesNo

    Rheumatic fever

    YesNo

    Artificial heart valve(s)

    YesNo

    Headaches

    YesNo

    Shortness of breath

    YesNo

    Artificial joint (s)

    YesNo

    Heart Murmur

    YesNo

    Sickle Cell Anemia

    YesNo

    Asthma

    YesNo

    Heart Problems

    YesNo

    Sinus trouble

    YesNo

    Bleeding abnormally with surgery

    YesNo

    Hepatitis type

    YesNo

    Stroke

    YesNo

    Blood disease, clotting disorders

    YesNo

    Herpes

    YesNo

    Slow healing wounds

    YesNo

    Cancer

    YesNo

    High blood pressure

    YesNo

    Swelling of ankles/feet

    YesNo

    Chemical dependency

    YesNo

    Immune deficiency

    YesNo

    Thyroid problems

    YesNo

    Chemotherapy

    YesNo

    Jaundice

    YesNo

    Tonsillitis

    YesNo

    Circulatory problems

    YesNo

    Kidney disease

    YesNo

    Tuberculosis

    YesNo

    Long term cortisone/steroid use

    YesNo

    Low blood pressure

    YesNo

    Tumor or growths

    YesNo

    Cough, persistent

    YesNo

    Mitral Valve prolapse

    YesNo

    Ulcers

    YesNo

    Diabetes

    YesNo

    Osteoporosis/osteopenia

    YesNo

    Venereal Disease

    YesNo

    DENTAL HISTORY:

    Have you had an allergic reaction to local or general anesthetics?

    YesNo

    Have you ever had trouble with/from prior dental treatment?

    YesNo