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Are you a student?
Do you have dental insurance?
Do you have medical insurance?
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04/11/2026Click to Sign
Gender
Have you ever been hospitalized?
Heart Trouble
High or Low Blood Pressure
Allergy to Latex
Heart Murmur
Radiation Treatment or Chemotherapy
Asthma
Fever Following Anesthesia or Excercise
Rheumatic Fever
Muscle or Neuromuscular Disorder
Stroke
TMJ (Temporomandibular Joint) Problems
Hepatitis, A, B, C, Other
Blood Transfusion
Kidney Disease
Muscle Spasms
Diabetes
Sleep Apnea
AIDS or HIV Infections
Anemia
Premedication for: heart valves, stents, artificial joints, screws, plates, etc.
Dark or Chocolate Colored Urin
Chemical Dependence on Alcohol or Drugs
Elevated or High Temperature Following Exercise
Are you currently taking any drugs or medications (including herbal, dietary supplements, vitamins)?
Do you have any allergies, or are you sensitive to any drug, medication, or food (soy, egg, sulfites)? If so, what?
Do you have a history of breast, prostate, or lung cancer, multiple myeloma, or metastatic bone cancer?
Have you ever taken oral bisphosphonates (Alendronate/Fosamax®), received IV bisphosphonates(Paminodrate/Aredia/Zolendronate/Reclast®/Zometa®) or received Prolia®/Denosumab?
Are you being treated for osteoporosis?
Do you bleed excessively following a cut, surgery or wound? If so, are you a Hemophiliac?
Are you a subject to fainting, dizziness, nervous disorder, convulsions, or epilepsy?
Have you ever had any breathing difficulty such as asthma, emphysema, chronic cough, pneumonia, tuberculosis,or lung disorder?
Have you ever had any adverse reactions to local anesthesia?
Do you have a family or personal history of malignant hyperthermia with unexpected death?
Have you ever had any adverse reactions to IV sedation or general anesthesia?
Do you use tobacco?
Are you pregnant?
Are you nursing?
Are you currently taking birth control pills?
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