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Please put a check in any of the following
conditions which you have or
have had.
Heart Disease:
Attack
Angina Pectoris
High Blood Pressure
Murmur
Rheumatic Fever
Congenital Lesions
Artificial Valve
Pacemaker
Heart Surgery
Mitral Valve Prolapse
Scarlet Fever
Anemia
Stroke
Kidney Trouble
Dialysis
Ulcers
Emphysema
Tuberculosis
Asthma
Hay Fever
Sinus Trouble
Allergies or Hives
Cancer of any type
Radiation Treatment
Are you taking any Medications? Yes
No
Please List Medications:
Do you have any disease not listed? Yes
If so, What?
Are you on a special diet?
Yes
Have you been hospitalized in the last two years?
Yes
If so, for what?
Name of Physician
Phone
Have you been advised that you need pre-medication
prior to dental
work? Yes
To the best of my knowledge, all of the preceding
answers are true and
correct. If I ever have any
change in my health, or if my medicines
change, I will
inform the dentist at the next appointment without fail.
Submitting this form constitutes acceptance of the prior statements.
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Patient Name:
Chemotherapy
Fen-Phen (Redux)
Cortisone Medication
Arthritis
Diabetes
Glaucoma
Pain in Jaw Joints
AIDS or HIV Positive
Venereal Disease
Liver Disease
Hepatitis A (infectious)
Hepatitis B (serum)
Hepatitis C
Artificial Joint or Prosthetic
Implant
Epilepsy or Seizures
Fainting or Dizzy Spells
Psychiatric Treatment
Bulimia or Anorexia
Bruise Easily
Abnormal Bleeding
Thyroid Disease
Snoring
Sleep Apnea
Surgery of any Type
Please
List Surgeries
Are you Pregnant? Yes
Using Birth Control Yes
Are you allergic to:
Penicillin
Local Anesthesia Medication
of any Type, Please List:
Are you receiving treatments now?
Yes
If so, describe:
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