Step 1 of 5 20% Medical / Physician InformationPatient name* First Middle Last Preferred nameBirth Date* Date Format: MM slash DD slash YYYY Are you currently under a physician's care?NoYesIf yes, please explainPhysician name, practice, phone#Date of last complete physical exam Date Format: MM slash DD slash YYYY History of serious head/neck injury?*NoYesHave you ever been hospitalized or had a major operation?*NoYesDo you have artificial heart valves or prostheses?*NoYesHave you had history of endocarditis?*NoYesDo you have a pacemaker?*NoYesDo you have artificial joints (knee, hip, shoulder, elbow)?*NoYesHave you taken antibiotics prior to dental appointments?*NoYesAre you on a special diet?*NoYesDo you consume non-diet soda?*NoYesDo you use controlled substances?*NoYesDo you consume alcohol?*NoYesDo you use tobacco?*NoYesIf 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 If "Other" please list Medications, Vitamin, Supplements, EtcAre you taking any medications, vitamins, supplements, pills or drugs?*NoYesMedication*Medication NameDosageDate StartedFor what reason? If more than five medications, please provide your own list or a list from your providerSupplements/VitaminsHave you ever taken Boniva, Fosamax, Actonel, or Reclast?*NoYes ConfirmationPatient/guardian signature indicates the information provided in this form is complete and accuratePlease type your name* First Last Please select today's date* Date Format: MM slash DD slash YYYY
