Patient Registration Form

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Gender
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10/27/2026Click to Sign
Penicillin
Novocaine
Aspirin
Codeine
Rubber or Latex
Had Complicated Tooth Extractions
Had Radiation Treatments
Had Chemotherapy
Excessive Bleeding
Pacemaker or Heart Surgery
Using Blood Thinners
Suspect Immonosuppression
Medication or Surgery Affecting Immune System
Performed Blood Transfusion
Do you or have you ever smoked tobacco products?(including e-cigarettes, vapes)
Do you or have you ever used tobacco products, if yes
Do you or have you ever used tobacco products, how often?
Do you drink alcohol?
Alcohol drinking level
Do you or have you ever used recreation drugs?
Heart Disease or Chest Pain
Diabetes
Tubercolosis
Venereal or Sexually Transmitted Disease
Lung Disease
Bronchitis
Rheumatic Fever
Heart Valve Damage or Murmur
Hemophilia
Hiatal Hernia
Prosthetic Heart Valve
Kidney Disease or Transplant
Kidney Disease
Other Implant
Stomach or Bowel Problems
Liver Disease
Hepatitis
Chronic Fatigue, Night Sweats, Chronic Cough, or Recurrent Mouth Sores
Oral Yeast or Fungal Infections
Chronic Diarrhea
Alcohol or Drug Dependency
Swelling of Feet or Ankles
Unintentional Weight Loss
Glaucoma or Other Eye Problems
Osteoporosis or Other Bone Disease
High or Low Blood Pressure
Fainting or Dizziness
Blood Diseases, Anemia, or Leukemia
Strokes or Heart Attack
Swollen Lymph Nodes
Cancer or Malignant Tumors
Shortness of Breath
Epilepsy or Seizure Disorder
Recurrent Earache or Other Ear Pain
TMJ
Nitroglycerine or Chest Patch
Steroids
Blood Thinners
Tranquilizers or Sedatives
Dilantin, Phenobarbital, or Seizure Medication
Digitalis or Other Heart Medicines
Birth Control Pills or Hormone Supplements
Insulin or Oral Diabetic Medicines
Thyroid Medications
Pregnant
Breastfeeding
Seek Pregnancy Confirmation First
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