Do you have or have you had any of the following? (Please check any that apply)
Cancer or tumorHeart diseaseArtificial joint or valveHigh or low blood pressurePacemakerTuberculosis or other lung problemsKidney diseaseHepatitis or other liver diseaseAlcoholismBlood transfusionDiabetesNeurologic conditionEpilepsy, seizures, or fainting spellsEmotional conditionArthritisHerpes or cold soresAIDS or HIV positiveMigraine headaches or frequent headachesAnemia or blood disordersAbnormal bleeding after extractions, surgery, or traumaHayfever or sinus troubleAllergies or hivesAsthma
Are you allergic to, or have you reacted adversely to:
Latex materialsPenicillin or other antibioticsLocal anesthetics ("Novocain")Codeine or other narcoticsBarbiturates, sedatives, or sleeping pillsAspirin
Are you taking any of the following?
AspirinAnticoagulants (blood thinners)Antibiotics or sulfa drugsHigh blood pressure medicineAntidepressants or tranquilizersInsulin, Orinase, or other diabetes drugNitroglycerinCortisone or other steroidsOsteoporosis (bone density) medicine
Women:
May be pregnant, expected due date Taking hormones or contraceptives
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the dentist. I understand that I am financially responsible for any balance.
