Are you in good health?
No
Yes
Has there been any change in your general health within the past year?
No
Yes
My last physical examination was on
January
February
March
April
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June
July
August
September
October
November
December
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Are you now under the care of a physician?
No
Yes
The name and address of my physician is
Have you been hospitalized or had a serious illness within the past 5 years?
No
Yes
If so, what was the problem?
Do you have or had any of the following diseases or problems?
a. Damaged heart valves or artificial heart valves, including heart murmur
No
Yes
b. Congenital heart lesions
No
Yes
c. Cardiovascular disease
No
Yes
Do you have pain in chest upon exertion?
No
Yes
Are you ever short of breath after mild exercise?
No
Yes
Do your ankles swell?
No
Yes
Do you get short of breath when you lie down, or do you require extra pillows when you sleep?
No
Yes
Do you have a cardiac pacemaker?
No
Yes
Allergy
No
Yes
Sinus trouble
No
Yes
Asthma or hay fever
No
Yes
Hives or a skin rash
No
Yes
Fainting spells or seizures
No
Yes
Diabetes
No
Yes
Do you have to urinate (pass water) more than six times a day?
No
Yes
Are you thirsty much of the time?
No
Yes
Does your mouth frequently become dry?
No
Yes
Hepatitis, jaundice or liver disease
No
Yes
Arthritis
No
Yes
Inflammatory rheumatism (painful swollen joints)
No
Yes
Artificial joint (joint replacement)
No
Yes
Stomach ulcers
No
Yes
Kidney trouble
No
Yes
Tuberculosis
No
Yes
Do you have a persistent cough or cough up blood?
No
Yes
Low blood pressure
No
Yes
Venereal disease
No
Yes
Epilepsy
No
Yes
Psychiatric problems
No
Yes
Cancer
No
Yes
AIDS or other immunosuppressive disorders
No
Yes
Other
Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?
No
Yes
Do you bruise easily?
No
Yes
Have you ever required a blood transfusion?
No
Yes
Do you have any blood disorder such as anemia?
No
Yes
Have you had surgery, x-ray or drug treatment for a tumor, growth, or other condition of your head or neck?
No
Yes
No
Yes
Anticoagulants (blood thinners)
No
Yes
Medicine for high blood pressure
No
Yes
Cortisone (steroids)
No
Yes
Tranquilizers
No
Yes
Antihistamines
No
Yes
Aspirin
No
Yes
Insulin, tolbutamide (Orinase) or similar drug
No
Yes
Digitalis or drugs for heart trouble
No
Yes
Nitroglycerin
No
Yes
Oral contraceptive or other hormonal therapy
No
Yes
Bisphosphonates
No
Yes
Other
Please list the names of all medications you are currently taking here:
No
Yes
Penicillin or other antibiotics
No
Yes
Sulfa drugs
No
Yes
Barbiturates, sedatives, or sleeping pills
No
Yes
Aspirin
No
Yes
Iodine
No
Yes
Codeine or other narcotics
No
Yes
Other
Please list all known allergies to drugs or medications here:
No
Yes
If so, explain
No
Yes
If so, explain
No
Yes
Are you wearing contact lenses?
No
Yes
Have you had anything to eat or drink in the last 4 hours?
No
Yes
Are you wearing removable dental appliances?
No
Yes
WOMEN
No
Yes
Do you have any problems associated with your menstrual period?
No
Yes
Are you nursing?
No
Yes
No
Yes
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the
inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other
member of his/her staff, responsible for any errors or omissions that I may have made in the completion
of this form.
