SeamlessDocs

Gender
Allergies
Have you had any adverse effects from dental treatment?
Do you take or have you taken:
Cardiovascular
Other Conditions
Dermal/Skin/Joints
Are you in good health?
Has there been any change in your general health in the past year?
Are you under a physician's care, or have you been in the past five years, including hospitalizations and surgeries?
Have you taken Cortisone or other steroids in the past 24 months?
Have you had ophthalmic (eye) surgery in the past 8 weeks?
Have you or your family had a reaction to dental or general anesthetic?
When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath, or because you feel very tired?
Neural/Sensory
Respiratory
Endocrine
Urinary
Hematologic
Gastrointestinal
Do you wish to talk with the doctor about anything privately?
Women Only
Are you currently enrolled in any Medicare or Medicare Advantage Plan?
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