Patient's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Work Phone

(###)

###

####

Mobile

(###)

###

####

Are you currently seeing a physician for treatment of a recent or ongoing medical condition? *

Yes

No

Have you been hospitalized within the last year? *

Yes

No

Have you ever had any serious medical trouble associated with any dental experience? *

Yes

No

Have you ever been advised to take antibiotics (like penicillin, etc.) before a dental appointment? *

Yes

No

Do you now or have you had any of the following Cardio vascular diseases? Check any that apply:

Heart disease

Hardening of the arteries

Heart attack

High blood pressure

Coronary bypass

Stroke

Angina

Heart murmur

Mitral valve prolapse

Congestive heart failure

Rheumatic fever or rheumatic heart disease Congenital heart defects

Prosthetic (artificial) heart valves

High blood pressure

High cholesterol

Shortness of breath after mild exercise

Shortness of breath when you lie down

Swelling of ankles

If you have a pacemaker, please list date of placement:

MM

DD

YYYY

If you have hepatitis, please select which type:

Type A

Type B

Type C

Other

Non-specific type

Do not know the type

If your hepatitis has required a blood transfusion, please select the date of that procedure:

MM

DD

YYYY

Are you HIV positive? *

Yes

No

Do you have reason to suspect you have been exposed to the HIV virus *

Yes

No

Do you have tuberculosis? *

Yes

No

Have you:

Had a TB test

Had a cough lasting more than three weeks

Coughed up blood

Check any that apply to you:

Allergies

Glaucoma

Alzheimer's

Heart Disease

Anemia

Herpes

Angina

Asthma

Arthritis

Autoimmune

Blood Disorder

Cancer

Chemo Therapy

Chronic Sinus

Cirrhosis

Depression

Diabetes

Drug/Alcohol treatment or disorder

Eating Disorder

Epilepsy/Seizures

Jaundice

Kidney Disease

Organ Transplant

Osteoporosis

Parkinson's

Radiation Treatment

Severe Headaches

Sexually Transmitted Disease

Skin Problems

Ulcers

Other

Do you consider yourself currently under O O an abnormally high amount of stress?

Yes

No

Have you had an unexplained or unplanned weight loss recently?

Yes

No

Do you drink alcohol?

Yes

No

Do you now or have you ever smoked?

Yes

No

If you were a smoker, when did you quit?

MM

DD

YYYY

Have you ever taken oral biophosphonates for bone density (Boniva, fosamax, etc.)?

Yes

No

Are youa allergic to any of the following (get hives, a rash, have trouble breathing, etc.):

Antibiotics (penicillin, tetracycline)

Local dental anesthetics (novocain)

Latex

Codeine

Aspirin

Barbiturates or Sedatives

Tranquilizers

Others

If you are currently pregnant, please select your expected delivery date:

MM

DD

YYYY

Have you reached menopause?

Yes

No

Are you on hormone replacement therapy?

Yes

No

If applicable, please list the date of your last mammogram:

MM

DD

YYYY

Please check this box if you are filling out this form on behalf of a minor.

I am filling out this information on behalf of a minor.

Please check this box to confirm all information has been submitted to the best of your ability. *

I have reviewed all information submitted on this form and attest that it is true to the best of my knowledge.