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Have you or any members of your family been a patient of our office
Local anesthetics
Penicillin Amoxicillin Keflex
Sulfa Drugs
Other Antiobiotics
Aspirin Ibuprofen Acetaminophen
Latex
Codeine Hydrocodone Percocet Tramadol
Other_2
None
Congestive Heart Disease
Diabetes
Low High Blood Pressure
Thyroid Disease
Heart Birth Defect
Hepatitis or Liver Disease
Heart Attack
Stomach Ulcers Reflux
Heart Surgery Valve replacement
Immune Deficiency
Chest Pain
AIDS HIV Positive
Rheumatic Fever
Arthritis
Heart Murmur
Hay Fever
Collagen or Vascular Disease
Respiratory Disease
Anemia
Sinusitis
Bleeding Problem
Asthma
Other Blood Disorder
Tuberculosis
Stroke
Emphysema COPD
Convulsions or Seizures
Glaucoma
Neurologic Disorder
Tumor or cancerous growth
Anxiety or Psychiatric Conditions
Radiation treatment or chemotherapy
Fainting Spells
Alcohol or drug abuse problem
Neck injury
Smoke or chew tobacco
Kidney Disease
Pregnant or nursing
Other_3
Osteoporosis Ost openia
Prosthetic Joints
None_2
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10/22/2026Click to Sign
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