Step 1 of 5 20% Medical / Physician InformationPatient name* First Middle Last Preferred name Birth Date* MM slash DD slash YYYY Are you currently under a physician's care? No Yes If yes, please explainPhysician name, practice, phone# Date of last complete physical exam MM slash DD slash YYYY History of serious head/neck injury?* No Yes Have you ever been hospitalized or had a major operation?* No Yes Do you have artificial heart valves or prostheses?* No Yes Have you had history of endocarditis?* No Yes Do you have a pacemaker?* No Yes Do you have artificial joints (knee, hip, shoulder, elbow)?* No Yes Have you taken antibiotics prior to dental appointments?* No Yes Are you on a special diet?* No Yes Do you consume non-diet soda?* No Yes Do you use controlled substances?* No Yes Do you consume alcohol?* No Yes Do you use tobacco?* No Yes If yes, how often and in what formWomen, please select all that apply Pregnant Trying to get pregnant Taking contraceptives Nursing ConditionsDo you have or have you had any of these conditions? AIDS Emphysema High blood pressure Osteoporosis Sinus problems Anemia Epilepsy/Seizures HIV Parathyroid disease STDs/STIs Arthritis Excessive bleeding Hives Psychiatric treatment Stomach problems Asthma Fainting Irregular heartbeat Radiation treatment Stroke Blood disorders Glaucoma Kidney problems Renal dialysis Thyroid disease Breathing problem Heart attack Leukemia Rheumatic fever Tonsillitis Cancer Hemophilia Liver problems Rheumatism Tuberculosis Chemotherapy Hepatitis A Low blood pressure Scarlet fever Tumors/Growths Cold sores Hepatitis B Hepatitis C Lung disease Shingles Diabetes Herpes Mitral valve prolapse Sickle cell anemia AllergiesAre you allergic or sensitive to any of the following?* Latex Penicillin / Amoxicillin Sulfa Aspirin Codeine Plastic Acrylic Local Anesthetics Nickel Metals Other None If "Other" please list Medications, Vitamin, Supplements, EtcAre you taking any medications, vitamins, supplements, pills or drugs?* No Yes Medication*Medication NameDosageDate StartedFor what reason? If more than five medications, please provide your own list or a list from your providerMax. file size: 10 MB.Supplements/VitaminsHave you ever taken Boniva, Fosamax, Actonel, or Reclast?* No Yes ConfirmationPatient/guardian signature indicates the information provided in this form is complete and accuratePlease type your name* First Last Please select today's date* MM slash DD slash YYYY
