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Name Prefix
Previous Patient
Family Previous Patient
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person responsible relation
person responsible relation 2
Employed
Belong to PPO or HMO
Marital Status
Are you a student
Insured party sex 1
Insured party sex 2
do you have dental insurance
Good Health
Health Changes
rheumatic fever
Under care of physician?
illness operation or hospitialized
unhealed recurrent injuries
have prosthetic join
heart valve or vascular graft
general anesthesia or iv sedation
you or familay unusual reactions anesthesia
antibiotics for dental treatment
chewing tobacco
damaged heart valves
difficulty breating
heart murmur
tuberculosis
high blood pressure
emphysema
alcohol intake
low blood pressure
Chest pain angina
heart attack
blood transfusion
irregular heartbeat
blood disorder
cardiac pacemaker
bruise easily
heart surgery
bleeding tendency
pneumonia, bronchitis
hepatitis
asthma
infectious monoculeosis
hay fever
gallbladder trouble
snoring
fainting spells
sleep apnea
convulsions epilepsy
smoke or vape
stroke
thyroid trouble
diabetes
autoimmune disease
low blood sugar
Methadone
Suboxone
delay in healing
kidney trouble
tumor or growth
high cholesterol
cancer radiation chemotherapy
are you on dialysis
chronic fatigue
arthritis
on a diet
osteoporosis
contact lenses
osteonecrosis
eye disease glaucoma
stomach ulcers
mental health problems
contagios diseases
removable dental appliance
sexually transmitted diseases
pain and clicking in jaws
problems with immune system
marijuana substance use disorder
history alcohol use disorder
blood thinners
taken diet pills
natural herbal supplements
bone density meds
Oxycodone
Fentanyl
Other_1
medication drug pills
local anesthetic
eggs
penicillin
sulfites
other antibiotics
sulfa drugs
sodium penthothal
aspirin
amoxicillin
codeine
latex
soy
doctor show know health
speak privately with doctor
cancer
heart disease
diabetes
anesthesia problems
Visit related to accident
Accident
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