Most Recent Physical Examination
What is your estimate of your general health?
Have you or anyone in your household had COVID-19?
Are you or have you had a fever in the last 24 to 48 hours?
Please advise us of any change in your medical history or medications, including over the counter, you are taking.
Have you ever been hospitalized for an illness or injury?
Have you ever had an allergic reaction to any medications?
Are you presently being treated for any illness?
Are you aware of a change in your overall health?
Please list ALL medications you take:
Have you ever had the following?
Abnormal Blood Pressure
Artificial Prosthesis (Heart Valve or Joints)
Anemia or other Blood Disorder
Prolonged bleeding due to slight cut
Head or Neck Injuries
Epilepsy, Convulsions, Seizures
Viral Infections & Cold Sores
Hives, Skin Rash, Hay Fever
Hepatitis B or C
Tumor/ Abnormal Growth
Thyroid or Parathyroid Disease
Any Lumps or Swelling in the Mouth
Alcohol / Drug Dependency
Often Exhausted or Fatigued
Subject to Frequent Headaches
Considered a touchy person
Often Unhappy or Depressed
Easily Upset or Irritated
Stomach or Dudenal Ulcer
How many years?
Are you taking birth control pills/ medication?
Are you pregnant?
How Far Along?
Do you take ED medication?
Please describe ANY OTHER medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment
I certify that I have read and I understand the questions asked. I certify I have answered these questions in completion and do not hold the practice, doctor(s), or team responsible for any errors or omission that I have made in completing these forms.
Patient/Legal Guardian Signature
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