1700 Hospital Drive
Santa Fe, NM 87505
Mon–Thu: 8:00 AM–5:00 PM
Fri: 8:00 AM–12:00 PM
It is important to provide accurate information to ensure a safe and successful surgery/procedure.
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?
Stomach Ulcers or Colitis?
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?
Seizures, Convulsions, Epilepsy, Fainting, Dizziness
Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion, Bruise Easily?
Liver Disease: Jaundice, Hepatitis
Radiation from X-ray, Cancer Treatment Radiation
Clicking or Popping of Jaw Joint, Pain Near Ear, Difficulty Opening Mouth, Grind or Clench Teeth?
Anticoagulants (Blood Thinners)?
Aspirin, Ibuprofen, Acetometaphin or other over-the-counter pain relievers?
High Blood Pressure medications?
Steroids (Cortisone, Prednisone, etc.)?
Insulin or Oral Anti-Diabetic drugs?
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?
Do you smoke or chew Tobacco?
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?
Have you had an HIV Blood test?
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?
Latex or Rubber products?
Metal of any kind?
Other allergies or reactions?
Are you pregnant, or is there any chance you might be pregnant?
Are you are using Oral Contraceptives?
Are you nursing?