You can download a form here, please fill it out ahead of time and bring it with you to your appointment. Or, simply use the form below to submit online. These questions are for your benefit and assure that treatment will take into consideration your past and present health status. Some questions may seem unrelated, but they are all associated with proper oral health.Please answer each question, checking Yes or No where applicable:Name* First Last Email* Sex*MaleFemaleToday's Date* Are you in good health?*YesNoDate of last physical exam* Are you now under the care of a physician?*YesNoFor what condition are you being treated*Have you ever had any serious Operations or been Hospitalized?*YesNoPlease Explain*Are you taking any medication?*YesNoPlease list:*Are you using any recreational drugs (marijuana, cocaine, etc.)?*YesNoWhat?*Are you sensitive or allergic to any drugs or medications?*YesNo Penicillin Tetracycline Sulfa Drugs Codeine Keflex Latex Other Please list:*Please check any of the following you may have or have had in the past? Anemia Angina Pectoris Arthritis Artificial Prosthesis Asthma Blood Disease Blood Transfusion Bruise Easily C-Pap Machine Cancer Cerebral Palsy Chemotherapy Cold Sores Cortisone Medicine Diabetes Difficulty Swallowing Drug Addiction Emphysema Epilepsy Excessive Bleeding Fainting Spells Glaucoma HIV/AIDS Head Injuries Heart Attacks Heart Failure Heart Lesions Heart Murmur Hemophilia Hepatitis (Type___) Herpes High Blood Pressure Joint Replacement Kidney Disease Liver Disease Mental Disorder Mitral Valve Prolapse Nervous Disorders Pace Maker Psychiatric Treatment Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Sickle Cell Disease Sinus Trouble Stomach Ulcers Stroke Taken Phen-Fen Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Other condition? Please explain*Do you need antibiotic pre-medication for your dental treatment?*YesNoDo you wear a cardiac pacemaker, or have you had heart surgery?*YesNoDo you smoke?*YesNoHow many packs per day?*Are you pregnant?*YesNoHow many months?*Do you have problems associated with your menstrual period?*YesNoDo you take birth control pills?*YesNoDental HistoryHave you ever had a local anesthetic? (Novocaine)*YesNoHave you ever had an unfavorable reaction from a local anesthetic?*YesNoHave you had any serious trouble associated with any previous dental treatment?*YesNoDo you suffer from persistent headaches/neck aches and/or pain in your jaw joint?*YesNoPlease explain*How long since your last full mouth X-rays?*YesNoHow long since your last dental treatment?*YesNoDoes dental treatment make you nervous?*YesNoHow would you rate your nervousness?*SlightModerateExtremeWhat would you like to change about your smile?*Are you interested in whitening your teeth?*YesNo* To the best of my knowledge all of the preceding answers are true and correct. If I ever have any change in my health, or medications, I will, without fail, inform the doctors at my next appointment. This iframe contains the logic required to handle AJAX powered Gravity Forms.