Are you Allergic to any of the following?

Please list all current medications you are taking:

Do you have or have you experienced any of the following?

Acid Reflux

Drug Abuse

Memory Loss

Alcohol Abuse

Emphysema

Mitral Valve Prolapse

Arthritis

Epilepsy

Occlusal Appliance

Heart

Glaucoma

Psychiatric Care

Asthma

Headaches

Radiation Treatment

Blood Transfusion

Heart Murmur

Rheumatic Fever

Chemotherapy

Heart Surgery

Sinus Problems

Congenital Heart Defect

Snoring

Depression

HIV/AIDS

Stroke

Diabetes

High Blood Pressure

Thyroid Problems

Anxiety

Hearing Impaired

Tuberculosis (TB)

Kidney Problems

Ulcers

Lever Disease

Vertigo

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.

Patient/Guardian/Parent Signature: