Patient's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Patient's Physician

First Name

Last Name

Physician's Phone Number

(###)

###

####

Have you been under the care of a physician for a particular condition?

Yes

No

Have you been hospitalized in the last 5 years?

Yes

No

Are you taking any medications?

Yes

No

Are you allergic to, or have you had any reaction to any medication or substance?

Yes

No

Do you have heart disease or any other heart condition? Please answer by checking Yes or No.

Heart Disease

Heart Attack

Chest Pain

Heart Surgery

Artificial Heart Valve

Heart Transplant

Heart Murmur

Mitral Valve Prolapse

Rheumatic Fever

Infective Endocarditis

Congenital Heart Defect

Pacemaker

Other Cardiovascular Disease

Do you have high blood pressure?

Yes

No

Do you have low blood pressure?

Yes

No

Have you had a joint replacement procedure? (hip, knee, shoulder)

Yes

No

Have you ever required premedication or antibiotics before dental treatment?

Yes

No

Have you ever been told you couldn’t give blood?

Yes

No

Do you have Hepatitis A, B, or C?

Yes

No

Have you been exposed to Hepatitis A, B, or C?

Yes

No

Do you have HIV or AIDS?

Yes

No

Have you been exposed to HIV or AIDS?

Yes

No

Have you been exposed to or do you have Tuberculosis (TB)?

Yes

No

Have you ever had cancer/tumors or been treated with radiation/chemotherapy?

Yes

No

Do you have diabetes? Type I or Type II?

Yes - Type I

Yes - Type II

No

Do you smoke or use tobacco?

Yes

No

Do you use any other drugs or substances?

Yes

No

Have you taken cortisone or steroids within the last 2 years?

Yes

No

Are you taking or have you ever taken Bisphosphonates (Fosamax, Actonel, Didrocal, Alendronate)?

Yes

No

Are you taking blood thinners?

Yes

No

Have you ever had abnormal bleeding (after tooth extraction, surgery, etc.)?

Yes

No

Are you pregnant

Yes

No

Are you nursing?

Yes

No

Are you using contraceptives or taking birth control pills?

Yes

No

Do you have or have you ever had any of the following conditions? Please answer by checking Yes or No.

Stroke

Thyroid Problems

Kidney Trouble

Liver Disease

Arthritis/Rheumatism

Ulcers

Glaucoma

Latex Sensitivity

Asthma

Emphysema/Chronic Cough

Swollen Ankles

Sinus Trouble

Anemia

Sickle Cell Disease

Hemophilia/Blood Disorder

Sexually Transmitted Infection/Disease

Cold Sores

Neurological Disorders

Epilepsy/Seizures

Headaches/Migraines

Psychiatric/Psychological Care

Nervous/Anxious

Fainting/Dizzy Spells

Have you had a blood transfusion?

Yes

No

I understand that the above information is necessary to provide me with dental care in a safe, efficient manner. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the dentist or his staff to any change in my health or medication. I, the undersigned, certify that I have provided an accurate and complete medical history and have not knowingly omitted any information. *

Yes