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Name
Address(Required)
MM slash DD slash YYYY

Medical History Questions

Are you under the care of a physician?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Do you or have you ever taken Fosamax, Boniva Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco or Vaper?
Do you use controlled substances?
Has a physician or previous dentist recommended that you take antibiotics or pre-medication prior to your dental appointment?
Women: Are you?
Are you allergic to any of the following?
Do you have any other known allergies?
Do you have or have you had any of the following diseases or medical conditions?
AIDS/HIV Positive(Required)
Cortisone Medicine(Required)
Hemophilia(Required)
Radiation Treatment(Required)
Alzheimer's Disease(Required)
Diabetes(Required)
Hepatitis A(Required)
Recent Weight Loss(Required)
Anaphylaxis(Required)
Renal Dialysis(Required)
Anemia(Required)
Easily Winded(Required)
Herpes(Required)
Rheumatic Fever(Required)
Angina(Required)
Emphysema(Required)
Epilepsy or Seizures(Required)
High Cholesterol(Required)
Scarlet Fever(Required)
Artificial Heart Valve(Required)
Excessive Bleeding(Required)
Hives or Rash(Required)
Shingles(Required)
Artificial Joint(Required)
Hypoglycemia(Required)
Sickle Cell Disease(Required)
Asthma(Required)
Fainting Spells/Dizziness(Required)
Irregular Heartbeat(Required)
Sinus Trouble(Required)
Blood Disease(Required)
Frequent Cough(Required)
Kidney Problems(Required)
Leukemia(Required)
Stomach / Intestinal Disease(Required)
Breathing Problem(Required)
Frequent Headaches(Required)
Liver Disease(Required)
Stroke(Required)
Bruise Easily(Required)
Genital Herpes(Required)
Low Blood Pressure(Required)
Lung Disease(Required)
Thyroid Disease(Required)
Chemotherapy(Required)
Hay Fever(Required)
Mitral Valve Prolapse(Required)
Tonsillitis(Required)
Chest Pains(Required)
Heart Attack/Failure(Required)
Osteoporosis(Required)
Ulcers(Required)
Convulsions(Required)
Heart Trouble/Disease(Required)
Psychiatric care(Required)
Venereal Disease(Required)
Yellow Jaundice(Required)
Have you ever had any serious illness not listed above?(Required)
Schedule your next visit
MM slash DD slash YYYY
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