Medical & Dental History

1. Are you being treated for any medical condition at the present time or have you been treated within the past year? If so, why?

Yes No Not Sure/Maybe

Please Specify

2. When was your last medical checkup?

3. Has there been any change in your general health in the past year. If yes, please explain.

Yes No Not Sure/Maybe

Please Specify

4. Have you had any surgeries in the past five years? If yes, please explain.

Yes No Not Sure/Maybe

Please Specify

5. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

Yes No Not Sure/Maybe

If 'Yes', please list

6. Do you have any allergies? If you answered yes, please list using the categories below.

No Allergies Medication & Antibiotics Latex/Rubber Products Other (please specify)

List Allergies

7. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.

Yes No Not Sure/Maybe

Please Specify

8. Do you have or have you ever had asthma?

Yes No Not Sure/Maybe

Please Specify

9. Do you have or have you ever had any heart or blood pressure problems?

Yes No Not Sure/Maybe

Please Specify

10. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

Yes No Not Sure/Maybe

Please Specify

11. Do you have a prosthetic or artificial joint?

Yes No Not Sure/Maybe

Please Specify

12. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV Infection, radiotherapy, chemotherapy?

Yes No Not Sure/Maybe

Please Specify

13. Have you ever had hepatitis (A,B,C or another form) jaundice or liver disease?

Yes No Not Sure/Maybe

Please Specify

14. Do you have a bleeding problem or bleeding disorder?

Yes No Not Sure/Maybe

Please Specify

15. Have you ever been hospitalized for any illness or operations? If yes please explain.

Yes No Not Sure/Maybe

Please Specify

16. Do you have or have you had any of the following?

chest pain, angina heart attack stroke shortness of breath rheumatic fever mitral valve prolapse heart murmur glaucoma pacemaker lung disease tuberculosis cancer herpes steroid therapy diabetes stomach ulcers arthritis seizures (epilepsy) kidney disease thyroid disease drug/alcohol dependency osteoporosis medication none of the listed apply

17. Are there any conditions or diseases not listed above that you have or have had?

Yes No Not Sure/Maybe

Please Specify

18. Are there any diseases or medical problems that run in your family?

Yes No Not Sure/Maybe

Please Specify

19. Do you smoke, chew or use tobacco products?

Yes No Not Sure/Maybe

Please Specify

10. Are you nervous during dental treatment?

Yes No Not Sure/Maybe

Please Specify

21. Are you breastfeeding or pregnant?

Yes No Not Sure/Maybe Only for women

If yes, what is the expected delivery date?

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Employer Information

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