Health And Dental History

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How did you hear about our office(Required)
INSURANCE DATA: (Please provide the insurance cards to our receptionist)
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1-Are you being treated for any medical conditions at present or within the past two years?(Required)
3-Are taking any medications, prescribed or non-prescription drugs or herbal/ supplement of any kind?(Required)
4-Do you have any allergies?(Required)
If yes, please list using the following categories:
5- Have you had an adverse reaction to any medications or injections?(Required)
6- Do you have or have you had any heart/blood pressure (High/Low) problems?(Required)
7- Have you ever been hospitalized for any illnesses or operations? If yes, please explain:(Required)
8- Are you taking any blood thinners?(Required)
9- Do you have or have you ever had any of the following? Please select
10- Are there any conditions or diseases not listed that you have or had?(Required)
11- Do you or have you ever had asthma?(Required)
12- Is there any family history of disease/medical problem? (E.g. diabetes/ cancer/ heart disease)(Required)
13- Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?(Required)
14- Do you have a prosthetic or artificial joint (i.e hip/ knee/ etc…)?(Required)
15- Have you ever been advised to take antibiotics (premedication) before visiting the dentist?(Required)
16- Do you have a bleeding problem or bleeding disorder?(Required)
17- Do you smoke/ chew tobacco products? If yes, for how long and how much?(Required)
18- Are you pregnant? If yes, what is the expected delivery date?
19- Are you nursing/ breast feeding?
20- Do you take birth control? If yes, which brand?
23- Have you ever had any complication following dental treatment?(Required)
24- Have you had any complications or unpleasant dental experiences?(Required)
What are you concerned about (Mark all that applies): Please select(Required)
Patient/Guardian Name(Required)
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