Have you ever had a serious illness, operation, or been in the hospital? *
Are you currently being treated for any medical condition? *
Have you had a medical examination in the last year? *
Are you presently taking any medications? *
Are you a smoker? *
Do you have or have you ever had any of the following? *
Are you allergic to any medication? *
Do you have any allergies or sensitivies? *
Do you require antibiotics before all dental procedures? *
Do you bleed abnormally? *
WOMEN: are you pregnant or trying to get pregnant?
Is there anything that the dentist should know regarding your medical history that has not been mentioned?