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Gender
Salutation
Have you ever been a patient of our practice
Has a family member ever been a patient of our practice
Person Responsible For Account
Person Responsible For Account
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04/25/2026Click to Sign
If yes, what type of accident
Congenital Heart Defects
Fainting Spells
Heart Disease
Under Physician Care
Changes To Health
Had Anesthesia or Sedatives
Family History of Anesthesia Reactions
Family History of Heart Disease Pre 40
TMJ Problems
Accident-Related Visit
Angina (Chest Pain)
High Blood Pressure
Low Blood Pressure
Heart Attack
High Cholesterol
Rheumatic Fever
Heart Valves/Implants/Grafts/Stents
Irregular Hearbeat/Heart Murmur
Pacemaker/ICD
Congestive Heart Failure
Other Heart Surgery
Palpitations
Breathing Problem
Stroke
Shortness of Breath
Joint Replacement Surgery
Bleeding or Clotting Disorder
Thyroid Disease
Alcohol Use
Lung Disease
Special Healthcare Needs
Asthma
Cancer
Sinus Trouble
Sleep Apnea/CPAP Use
Radiation
Diabetes
Kidney Disease
Chemotherapy
Dialysis
Stomach Ulcers
Gastroc Reflux/GERD
Liver Disease/Cirrhosis/Hepatitis
Biphosphonate Use
Anemia
Blood Clots, DVT, or PE
Sexually Transmitted Infections
Blood Thinners
HIV/AIDS
Tobacco Use
Dementia/Alzheimer's
Seizures/Epilepsy
Alcohol or Drug Addiction Treatment
Glaucoma
Mental Health Concerns
Recreational Drug Use
Is there any Chance you could be pregnant
Breastfeeding
Birth Control Pills
If you are having IV sedation or general anesthesia today, have you had anything to eat or drink in the last 8 (eight) hours
Need Private Counsel
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04/25/2026Click to Sign
Is it ok to send you a voicemail?
Is it ok to send you a SMS text?
Is it ok to send you an email?
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Is it ok to leave you a voicemail?
Is it ok to leave you a voicemail?
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04/25/2026Click to Sign
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