Medical Information Leave this field blank Name: Gender Male Female Prefer Not To Say Other Address (Home): Email Address: Name: Relationship: Name of Family Doctor: Phone or Address: Name of Medical Specialist: Area of Specialty: Member ID/certificate numbers Name of Policy Holder Insurance Company: Group/Individual Policy No.: Name of Policy Holder Insurance Company: Group/Individual Policy No.: Certificate Number/Member ID 1. Are you being treated for any medical condition at the present of have been treated within the past year? Yes No Not Sure If so why? 3. Has there been any change in your general health in the past year? Yes No Not sure Maybe Please explain 4. Are you taking any medicationss, non-prescription drugs or herbal supplements of any kind? Yes No Not sure Maybe Please list. 5. Do you have any allergies? Yes No Please list using the categories below. a.) Medications b.) Latex/Rubber products c.) Other e.g. hay fever,foods... 6. Have you ever had a peculiar or adversee reaction to any medicines or injections? Yes No Not sure Maybe Please explain. 7. Do you have, or have you ever had asthma? Yes No Not sure Maybe 8. Do you have, or have you ever had any heart or blood pressure problems? Yes No Not sure Maybe 9. Do you have, or have you ever had a heart murmur, mitral valve prolapses or rheumatic fever? Yes No Not sure Maybe 10. Do you have a prostheic or artificial joint? Yes No Not sure Maybe 11. Have you ever been advised by your doctor to take antibiotics before dental treatment? Yes No Not sure Maybe 12. Do you have any conditions or therapies that could affect your immune system e.g. Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy? Yes No Not sure Maybe 13. Have you ever had hepatitis, jaundice, or liver disease? Yes No Not sure Maybe 14. Do you have bleeding problem or operations? Yes No Not sure Maybe Please explain. 15. Have you ever been hospitalized for any illness or operations? Yes No Not sure Maybe 16. Do you have, or have you ever had any of the following? Chest pain Angina Shortness of Breath Pacemaker Steroid therapy Seizures (Epilepsy) Drug/Alcohol dependency Heart Attack Diabetes Stroke Tuberculosis Thyroid Disease Arthritis Therapy Lung Disease Cancer Stomach Ulcers Prosthetic Heart Valve Kidney Disease Diet Pill No Please explain. 17. Are there any conditions or disease not listed above that you have or had? Yes No Not sure Maybe What? 18. Do you smoke or ches tobacco products? Yes No 19. Are there any condition or disease not listed above that you have or have had? Yes No Not sure Maybe Are you nervous during dental treatment from a scale to 1-10, 1 being the least and 10 being not nervous? For women only: Are you breast feeding or pregnant? (optional) Breast feeding Pregnant Oral surgery? (surgery in or about the mouth/jaw joint, or implant surgery inn one or both of your jaw joints?) Yes No Are there any growths or sore spots in your mouth? Yes No Do your gums bleed when brushing or eating, or do you suffer from pain or swelling of your gums? Yes No Have you notices any loose teeth, or have any of your teeth shifted? Yes No Are any of your teeth sensitive to heat, cold, sweets, or pressure? Yes No Do you feel that you have bad breath? Yes No Popping or clicking of jaws? Yes No Difficulty in opening or closing? Yes No Send