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04/12/2026Click to Sign
Seizures, Convulsions, Epilepsy, Fainting, Dizziness
Radiation from X-ray, Cancer Treatment Radiation
Anticoagulants (Blood Thinners)?
Aspirin, Ibuprofen, Acetometaphin or other over-the-counter pain relievers?
Insulin or Oral Anti-Diabetic drugs?
Are you in good health ?
Has there been any change in your general health in the past year?
Are you now under a physician’s care for a particular problem?
Have you ever had any serious illness, surgery or hospitalization?
Rheumatic Fever or Rheumatic Disease?
Congenital Heart Disease?
Kidney Disease?
Diabetes?
Thyroid Disease?
Arthritis?
Stomach Ulcers or Colitis?
Glaucoma?
Osteoporosis?
Implants placed anywhere in your body (Heart Valve, Pacemaker, Hip, Knee)?
Sinus or Nasal problems?
Any disease, drug or transplant operation that has depressed your immune system?
Cardiovascular Disease: Heart Attack, Heart Trouble, Heart Murmur, Angina, Stroke?
Lung Disease: Asthma, Emphysema, COPD, Chronic Cough, Bronchitis, Pneumonia?
Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion, Bruise Easily?
Liver Disease: Jaundice, Hepatitis
Clicking or Popping of Jaw Joint, Pain Near Ear, Difficulty Opening Mouth, Grind or Clench Teeth?
Antibiotics?
High Blood Pressure medications?
Steroids (Cortisone, Prednisone, etc.)?
Tranquilizers?
Digitalis, Inderal, Nitroglycerin or other heart drug?
Are you taking or have you ever taken Bisphosphonates for osteoporosis, multiple myeloma?
Are you currently taking any antidepressant or anxiety medication?
Latex or Rubber products?
Food products?
Other allergies or reactions?
Do you smoke or chew Tobacco?
Have you ever had Hepatitis A, B, or C?
Local Anesthesia (Novacain, etc.)?
Penicillin or other antibiotics?
Aspirin or Ibuprofen?
Codeine or other pain killers?
Metal of any kind?
Is there any personal or family history of Alcohol, Chemical Dependency?
Have you had any problems associated with any previous dental treatment?
Have you ever had a bone density scan?
Are you pregnant, or is there any chance you might be pregnant?
Are you nursing?
Are you are using Oral Contraceptives?
Have you had an HIV Blood test?
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