The following information is required to enable us to provide you with the best possible dental care.
All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
Are you currently being treated for any medical condition or have you been treated within the past year?
If yes, please explain:
When was your last medical checkup?
Has there been any change in your general health in the past year?
If yes, please explain:
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
If yes, please list them:
Do you have any allergies?
If yes, please list them using the categories below:
medications
latex/rubber products
other (e.g. hay fever, seasonal/environmental, foods)
Have you ever had a peculiar or adverse reaction to any medicines or injections?
If yes, please explain:
Do you have or have you ever has asthma?
Do you have or have you ever had any heart or blood pressure problems?
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the hearth (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
Do you have a prosthetic or artificial joint?
Do you have any condition or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV, infection, radiotherapy, chemotherapy)?
Have you ever had hepatitis, jaundice or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illness or operations?
If yes, please explain:
