Prefix Mr. Mrs. Ms. Dr. Rev.

Gender Male Female

Gender Male Female

Relationship to patient Spouse Parent

Is insured a patient? Yes No

Relationship to insured Self Spouse Child

Please check if taking any of the following: Plavix Coumadin Aspirin (includes baby aspiring) Thyroid medicine Inderal, Corgard, Blockadren, Coreg, Cartrol Digitalis Tofranil, Elavil Decongestants ACE Inhibitors - Accupril, Prinivil, Univasc, Vasatec, Captopril Prozac, Paxil, Zoloft, Celexa, Tagamet, Effexar Fosamax, Actonel, Boniva, Zometa I-V Albuterol Birth Control

Medical Conditions (Past or Present) Hyperthyroidism Diabetes Heart disease Kidney Disease Liver Disease COPD/Asthma Pregnant Cancer Osteoporosis Artificial joints Rheumatic Heart Disease Mitral Valve Prolapse AIDS

Hepatitis Type A (food) Type B (serum/blood) Type C

Allergies Penicillin Codeine Bisilfites (fresh fruits) Sulpha Drugs Keflex Tetracyclines Latex

Have you been examined by a dentist in the last year? Yes No

Do you grind your teeth? Yes No

Do you like the color of your teeth? Yes No

Do you drink carbonated beverages? Yes No

Do you smoke/or use any other tobacco products? Yes No

Have you had radiation treatment in head/neck area? Yes No

Have you been advised to be premedicated with antibiotic prior to dental work? Yes No

Would you like to talk about being sedated to relieve anxiety prior to dental work? Yes No