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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