Your Name (required)

Nickname

Your Email (required)

Age

Name of Physician/and their specialty

Most recent physical examination

Purpose

What is your estimate of your general health?
ExcellentGoodFairPoor

DO YOU HAVE or HAVE YOU EVER HAD?(All Fields are Required)

1.Hospitalization for illness or injury
YesNo

2.Do you have any allergies

YesNo

If yes please check any that apply
aspirin, ibuprofen, acetaminophen, codeine penicillinerythromycintetracyclinesulfa localanestheticfluoride metals (nickel, gold, silver)latexother

If choose other please state:

3. Heart problems, or cardiac stent within the last six months
YesNo

4. History of infective endocarditis
YesNo

5. Artificial heart valve, repaired heart defect (PFO)
YesNo

6. Pacemaker or implantable defibrillator
YesNo

7. Artificial prosthesis (heart valve or joints)
YesNo

8. Rheumatic or scarlet fever
YesNo

9. High or low blood pressure
YesNo

10. A stroke (taking blood thinners)
YesNo

11. Anemia or other blood disorder
YesNo

12. Prolonged bleeding due to a slight cut (INR > 3.5)
YesNo

13. Emphysema, sarcoidosis
YesNo

14. Tuberculosis
YesNo

15. Asthma
YesNo

16. Breathing or sleep problems (i.e. snoring, sinus)
YesNo

17. Kidney disease
YesNo

18. Liver disease
YesNo

19. Jaundice
YesNo

20. Thyroid, parathyroid disease, or calcium deficiency
YesNo

21. Hormone deficiency
YesNo

22. High cholesterol or taking statin drugs
YesNo

23. Diabetes (HbA1c)
YesNo

24. Stomach or duodenal ulcer
YesNo

25. Digestive disorders (i.e. gastric reflux)
YesNo

26. Osteoporosis/osteopenia (i.e. taking bisphosphonates)
YesNo

27. Arthritis
YesNo

28. Glaucoma
YesNo

29. Contact lenses
YesNo

30. Head or neck injuries
YesNo

31. Epilepsy, convulsions (seizures)
YesNo

32. Neurologic problems (attention deficit disorder)
YesNo

33. Viral infections and cold sores
YesNo

34. Any lumps or swelling in the mouth
YesNo

35. Hives, skin rash, hay fever
YesNo

36. STI / STD
YesNo

37. hepatitis
YesNo

38. HIV / AIDS
YesNo

39. Tumor, abnormal growth
YesNo

40. Radiation therapy
YesNo

41. Chemotherapy
YesNo

42. Emotional problems
YesNo

43. Psychiatric treatment
YesNo

44. Antidepressant medication
YesNo

45. Alcohol / street drug use
YesNo

ARE YOU

46. Presently being treated for any other illness
YesNo

47. Aware of a change in your health (i.e. fever, new cough)
YesNo

48. Taking medication for weight management (i.e. fen-phen)
YesNo

49. Taking dietary supplements
YesNo

50. Often exhausted or fatigued
YesNo

51. Experiencing frequent headaches
YesNo

52. A smoker, smoked previously or use smokeless tobacco
YesNo

53. Considered a touchy person
YesNo

54. Often unhappy or depressed
YesNo

55. FEMALE - taking birth control pills
YesNo

56. FEMALE - pregnant
YesNo

57. MALE - prostate disorders
YesNo

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

List all medications, supplements, and or vitamins taken within the last two years

Drug

Purpose

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

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