Birthday*

Are you being treated for any medical condition at the present or have you been treated within the last year?*

Has there been any change in your general health in the past year?*

When was your last medical checkup?*

Do you have any conditions that could affect your immune system e.g. Leukemia, HIV infection +/- tested, Lupus?*

Are you undergoing any therapies that could affect your immune system e.g. radiotherapy or chemotherapy? *

Are you currently taking any steroid or cortisone?*

Do your ankles, feet, or hands swell?*

Are you allergic to any medications?*

Are you allergic to any of the following:*

Are you allergic to any food? *

Do you have any other allergies that we should be aware of?*

Have you ever had any peculiar or adverse reaction to any medicine or injections?*

Are you taking or have you ever taken osteoporosis medication (e.g. Fosfamax, Actonel)?*

Are you currently taking any prescription medications?*

Have you been advised against taking any medication?*

Are you taking any nonprescription drugs?*

Do you take any recreational drugs on a regular basis?*

Are you taking any herbal supplements of any kind?*

Do you have diabetes?*

Do you have or have you ever had any of the following:*

Do you have or have you ever had any conditions or diseases not previously listed that we should be aware of?*

Are there any diseases or medical problems that run in your family?*

Do you have bleeding problems or bleeding disorders?*

Do you have or have you ever had replacement or repair of heart valve or stent?*

Do you have or have you ever had an infection of the heart (infective endocarditis)?*

Have you had a transplant (heart, lung, organs, endocrine disease)? *

Do you have a heart condition from birth (congenital heart disease, lesions)? *

Do you have or have you ever had blood pressure problems? *

Do you have a prosthetic or artificial joint?*

Have you ever been hospitalized for any illness or operations?*

Have you ever had any injury or surgery to your face or jaws?*

Do you smoke or chew tobacco products?*

Are you nervous during dental treatment?*

Is there anything else about your health we should be aware of?*

Do you wish to speak to a doctor privately about any problem or medical conditions?*

Has the child patient recently had any of the following?*

Are there any immunizations that the child is not up to date with?*

For women only: Are you breastfeeding?*

For women only: Are you pregnant?*

Date*