Are you now or have you been under the care of a physician during the past 5 years?
Do you take any medications regularly?
*** Have you ever had any surgeries or hospitalizations?
Have you ever had breathing difficulty such as asthma, emphysema, chronic cough, pneumonia, tuberculosis, or any other lung disorder?
Check any of the following which you have or had in the past:
Are you allergic to ANY medications?
Have you ever had undesirable effects from taking these drugs?
Do you have popping or clicking in your jaw?
Have you had TMJ problems in the past?
Do you bleed easily or for long periods?
Do you now have a cold, cough or sinus trouble?
Do you wear contact lenses?
If female…are you pregnant?
When you walk up stairs or exercise, do you ever experience chest pain or shortness of breath or have to stop simply because you are very tired?
Do your ankles swell during the day?
Do you use more than 2 pillows to sleep?
Do you have any disease, problem, or condition not listed above?
Do you have any food allergies?
To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my medical history (including changes in medicine) or health, I will inform the doctor of dentistry at my next appointment.
Electronic Disclosure, Electronic Signature and Electronic Statements Agreement
Please read this Electronic Records Disclosure and Agreement carefully:
By checking the boxes on the website for patient forms, AND, by typing your name in the e-sign box here, you consent to the electronic delivery of the disclosures, information you provided, terms and conditions and any other documents to be included in your electronic and paper copy records. You also agree that we do not need to provide you with additional paper (non-electronic) copies of the disclosures, agreements, change notices, terms and conditions and any other documents, unless specifically requested. Once you consent to the disclosures and inclusion of your HIPAA protected information to be included in your records, you may request paper copies, which may result in a small copying fee.