Signature will be recorded later.
Date: 10/22/2019Capitola Dental · P|831-475-2313 · 617 Capitola Ave, Capitola CA, 95010 · capitadental@gmail.com · www.capitoladental.comPace MakerHeart MurmurCancerHeart TroubleDrug AddictionDiabetesBlood DiseaseMitral Valve ProlapseRadiation TherapyHerpesProsthetic JointTuberculosisAIDS/ HIVEpilepsyLow Blood PressureSpontanious BleedingHepatitis A, B, CHigh Blood PressureAsthmaPsychological DisorderLatex AllergyOrgan TransplantAlcoholismUlcerDysenteryDo you ever have an unusual reaction to dental anesthetic, Penicillin, Barbiturates, Aspirin, Codeine, Sulfa, other?Do you have any chest pain on exertion?Check any medical conditions you may have:Do you ever have hives or skin rashes?Do you bleed a long time when you are cut?Do you have a pacemaker?Do you often feel exhausted or fatigued?Have you ever been seriously ill?Have you been a patient in the hospital in the last 3 years?Have there been any changes in your health this year?Are you pregnant?Please check the box if answer is yes.Medical Doctor:DOB:First Name:Last Name:Medical HistoryDr. Robert C. Schellentrager DMD General and Cosmetic Dentistry