Information that you may feel insignificant could actually be related to your dental health. Answering the following questions will provide us with a thorough understanding of your physical condition for proper recommendations regarding your dental care. This information is strictly confidential. Thank you for completing all questions.

Do you have or have you ever been treated for:

Any Heart Problems*

Heart Attack*

Angina*

Bypass*

Pacemaker*

Stroke*

High Blood Pressure*

Low Blood Pressure*

Heart Murmur*

Mitral Valve Prolapse*

Heart Valve Defect*

Heart Valve Replacement*

Rheumatic Fever*

Artificial Joints (Hip/Knee)*

Any Blood Disorders*

Anemia*

Hemophilia*

Sickle Cell Trait*

Blood Transfusions*

Allergic Reactions to (Hives/Swelling)*

Latex (Gloves)*

Penicillin*

Erythromycin*

Sulfa*

Codeine*

Aspirin*

Local Anesthetic (Novocaine)*

Do you smoke?*

Lung/Breathing Problems*

Asthma*

Bronchitis*

Emphysema*

Tuberculosis*

Sinus Trouble*

Diabetes*

Difficulty in Healing*

Liver Problems/Dysfunction*

Hepatitis/Jaundice*

Kidney Problems/Dysfunction*

Stomach Trouble/Uclers*

Alcoholism*

Drug Abuse*

Nervous or Mental Disorder*

Epilepsy or Seizures*

Adrenal/Pituitary Problems*

Sexually Transmitted Diseases*

Other Infectious Diseases*

HIV/AIDS*

Cancer/Tumor*

Other Growths*

Chemotherapy/Radiation Therapy*

Women Only: Are you pregnant?*

Are you aware of being allergic to any other medications or substances?*

Do you take antibiotic pre-medication prior to dental appointments?*

Are you currently treated by a physician?*

Are you presently taking any medications, pills or tonics?*

Is there any condition or problem relating to your medical history that has not been mentioned?*