Are you taking any medications (including over the counter and dietary supplements)?Are you allergic to any medications?If "yes" then please list bellow:YesNoNoYesCity,StateAre any of your teeth presently senstive to cold, hot, biting or sweets?Pharmacy NameNoName of Medical Doctor:Medical and Dental HistoryYesAre you interested in hearing about ways to improve your smile?Date: 11/16/2018
Signature will be recorded later.
PhoneCity/State:Emergency ContactRelationshipIf "Yes" then please list all of them bellow:Any unusual reaction to dental injections?Tobacco use? If so, what kind and how much?Do you have a history of any other conditions not listed above? If yes please list bellow:Radiation to the head or neck?Kidney or other urological problems?Pacemaker or Implanted Defibrillator?High or Low Blood Pressure?History of Heart Attack or Stroke?Liver Disease (including Hepatitis)?Chronic Sinus Infections or History of Sinus Surgery?Asthma?History of Cancer?Stomach or Digestive Issues(including ulcers)?Heart Valve Problems including replacement or defects?Diabetes?Suppressed Immune Sys.?Latex Allergy?YesNoYesNoYesHistory of Cardiac Stents?History of Joint Replacement, if so when?NoDo you participate in sports?First Name:Last Name:DOB