420 N Evergreen Rd # 400, Spokane Valley, WA 99216

Please fill out all the information to the best of your knowledge. All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you.
Birth Date:
Date Created:
Are you under a physician's care now?
Yes No
Have you ever been hospitalized or had a major operation?
Yes No
Have you ever had a serious head or neck injury?
Yes No
Are you taking any medications, pills, or drugs?
Yes No
Do you take, or have you taken, Phen-Fen or Redux?
Yes No
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes No
Are you on a special diet?
Yes No
Do you use tobacco?
Yes No
Do you use controlled substances like alcohol or marijuana?
Yes No
 

Women: Are you...

Pregnant/Trying to get pregnant?
Nursing?
Taking oral contraceptives?
 

Are you allergic to any of the following?

Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetics
 

Do you have, or have you had any of the following?

AIDS/HIV Positive Yes No

Alzheimer's Disease Yes No

Anaphylaxis Yes No

Anemia Yes No

Angina Yes No

Arhritis/Gout Yes No

Artificial Heart Valve Yes No

Artificial Joint Yes No

Asthma Yes No

Blood Disease Yes No

Blood Transfusion Yes No

Breathing Problems Yes No

Bruise Easily Yes No

Cancer Yes No

Chemotherapy Yes No

Chest Pains Yes No

Cold Sores/Fever Blisters Yes No

Congenital Heart Disorder Yes No

Convulsions Yes No

Cortisone Medicine Yes No

Diabetes Yes No

Drug Addiction Yes No

Easily Winded Yes No

Emphysema Yes No

Epilepsy or Seizures Yes No

Excessive Bleeding Yes No
Excessive Thirst Yes No

Fainting Spells/Dizziness Yes No

Frequent Cough Yes No

Frequent Diarrhea Yes No

Frequent Headaches Yes No

Genital Herpes Yes No

Glaucoma Yes No

Hay Fever Yes No

Heart Attack/Failure Yes No

Heart Murmur Yes No

Heart Pacemaker Yes No

Heart Trouble/Disease Yes No

Hemophilia Yes No

Hepatitis A Yes No

Hepatitis B or C Yes No

Herpes Yes No

High Blood Pressure Yes No

High Cholesterol Yes No

Hives or Rash Yes No

Hypoglycemia Yes No

Irregular Heartbeat Yes No

Kidney Problems Yes No

Leukemia Yes No

Liver Disease Yes No

Low Blood Pressure Yes No

Lung Disease Yes No
Mitral Valve Prolapse Yes No

Osteoporosis Yes No

Pain in Jaw Joints Yes No

Parathyroid Disease Yes No

Psychiatric Care Yes No

Radiation Treatments Yes No

Recent Weight Loss Yes No

Renal Dialysis Yes No

Rheumatic Fever Yes No

Rheumatism Yes No

Scarlet Fever Yes No

Shingles Yes No

Sickle Cell Disease Yes No

Sinus Trouble Yes No

Spina Bifida Yes No

Stomach/Intestinal Disease Yes No

Stroke Yes No

Swelling of Limbs Yes No

Thyroid Disease Yes No

Tonsillitis Yes No

Tuberculosis Yes No

Tumors or Growths Yes No

Ulcers Yes No

Venereal Disease Yes No

Yellow Jaundice Yes No

 
Have you ever had any serious illness not listed above?
Yes No
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing icnorrect information can be dangerous to my (or patients) health. It is my responsibility to inform the dental office of any changes in medical status.
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