First Name
Last Name
Email
Phone Number
General Health:
ExcellentGoodFairPoor
Under a physician's care now?
YesNo
Any hospitalization in the past 5 years?
If you answered "yes" above, please explain.
Any serious illnesses/surgeries?
Use tobacco in any form?
Is pre-medication required before dental visits due to heart condition or artificial joint?
Taking any prescription or daily OTC medications/drugs?
If yes, list details in the Medication Section.
Currently nursing?
Currently pregnant?
If you answered "yes" above, what is your due date?
Do you know of any reason why routine dental procedures might pose a risk to you, our staff, or other patients?
Is there anything important about your medical condition we have not asked?
ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):
ACID REFLUXADHDAIDS/HIVANEMIAANOREXIAANXIETYARTIFICIAL HEART VALVEARTIFICIAL JOINTSARTHRITISASTHMAAUTISM/ASPERGER'SBLEEDING DISORDERBULIMIACANCER/MALIGNANCYCEREBRAL PALSYCHEMICAL DEPENDENCYCHICKEN POXCONVULSIONSDEPRESSIONDIABETESDIZZINESS/FAINTINGEPILEPSY/SEIZURESFREQUENT EAR INFECTIONSFREQUENT HEADACHESHEARING PROBLEMSHEART ATTACKHEART DISEASEHEART MURMURHEPATITISHIGH BLOOD PRESSUREKIDNEY DISEASELIVER PROBLEMSMITRAL VALVE PROLAPSEMONONUCLEOSISPACEMAKERPSYCHIATRIC TREATMENTRADIATION/CHEMORESPIRATORY DISEASERHEUMATIC FEVERSINUS PROBLEMSSTROKETHYROID CONDITIONTUBERCULOSISULCERSVENEREAL DISEASEOTHER (Explain below)None of these
If you answered "Other" above, please explain.
ALL PATIENTS: ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):
ASPIRINANESTHETIC – LOCALBARBITURATESCODEINEDAIRYLATEXLACTOSE INTOLERANCEMETAL SENSITIVITYNITROUS OXIDE SEDATIONSLEEPING PILLSSULFA DRUGSPENICILLIN/OTHER ANTIBIOTICSOTHER (Explain below)None of these
ALL PATIENTS: ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):
ANTIBIOTICS/SULFA DRUGSBLOOD THINNERSINSULINOTHER DIABETIC MEDICATIONSOTHER (VITAMINS)ANTIHISTAMINES/ALLERGYCANCER/CHEMO MEDICATIONSNITROGLYCERINRECREATIONAL DRUGSDAILY ASPIRINCORTISONE/STEROIDSORAL CONTRACEPTIVESTHYROID MEDICATIONSBLOOD PRESSURE MEDICATIONSHEART MEDICATION/DIGITALISOSTEOPOROSIS MEDICATIONSTRANQUILIZERS
Please list any additional medications.
Drug Name
Dosage
Reason Prescribed
- Remove Medication+ Add Medication