Language
English (US)
Spanish (Latin America)
Medical History
Full Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Are you currently taking any medications? Please specify
*
Do you have any allergies to medications? Please specify
*
Do you have a latex allergy?
*
Yes
No
Do you have any allergies to dental materials? Please specify
*
Are you under the care of a physician for any medical conditions? Please specify
*
Have you had your tonsils and/or adenoids removed?
*
No
Tonsils
Adenoids
Tonsils and Adenoids
Please list any surgeries you have had:
*
Do you currently use any form of nicotine?
*
Please Select
Yes
No
Please check if you have had or currently have any of the following conditions:
*
I do not have any of the below conditions
AIDS/HIV
Anemia
Asthma
Bone Disorder
Blood Disease
Bronchitis
Cancer
Developmental Disorder
Diabetes
Dizziness or Fainting
Emotional Problems
Endocrine Disorder
Epilepy
Facial/Jaw/TMJ Pain
Frequent Headaches
Growth Disorders
Heart Condition
Heart Murmur
Hearing Impaired
Hepatitis
Hernia Repair
Herpes/Cold Sores
Hives/Rash
Kidney Disorder
Liver Disorder
Mouth Breather
Mitral Valve Prolapse
Nervous/Anxious
Prone to colds
Prone to ear infections
Prone to sore throats
Prolonged Bleeding
Psychiatric Care
Rheumatic Fever
Tonsilitis
Trauma to face or Jaw
Tuberculosis
Ulcer
Vertigo
Vision Impaired (partial or complete blindness)
Other
Signature
*
Clear
Date
*
Submit
Should be Empty: