Welcome to our office... Let's get aquainted.
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Please Answer Each Question

Poor health
Recent illness
Heart murmur
Nose obstruction
Heart or chest pain
Frequent swollen ankles
Facial x-ray treatment
Cortisone or ACTH
Bleeding tendency
Herpes
Hepatitis
Diabetes
Heart trouble
High blood pressure
Kidney disease
Liver disease
Lung disease
Asthma
Bronchitis
Rhumatic fever
Convulsions
HIV positive
AIDS
Anemia
Allergic to:
Penicillin
Metal
Latex
Local Anesthetic
Codeine
Aspirin
Other drugs
Must you sleep with your head on more than one pillow?
Have you ever been put to sleep for an operation?
Are you pregnant?
Are you under the care of a physician?
Are you now taking medicine of any kind
Do you require premedication at dental visits?
Have you ever responded unfavorably to medical or dental care?
Do you get short of breath after a little exertion?
Have you ever been hospitalized within the last 5 years?