Your Name (required) Your Email (required) Phone Number (required) Are you under a physician's care now? YesNo Have you ever been hospitalized or had a major operation? YesNo If yes, please explain: Are you taking any medications, pills, or drugs? YesNo Please list all medications and dosage Do you take, or have you taken, PhenFen or Redux? YesNo Do you use tobacco? YesNo Do you use controlled substances? YesNo Pregnant/Trying to get pregnant? YesNo Currently nursing? YesNo Taking oral contraceptives? YesNo Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic) (required) AspirinAcrylicErythromycinIodineLatexLocal AnestheticsMetalNovocaineNitrous OxidePenicillinSulfa DrugsTetracyclineValiumXylocaineNone of the Above Do you have, or have you ever had any of the following medical conditions? (Please select all that apply) (required) AnemiaChemotherapyCold Sores/Fever BlistersCortisone MedicationExcessive BleedingFrequent CoughFrequent HeadachesHay FeverHemophiliaHigh Blood PressureHives or RashKidney ProblemsLiver DiseaseParathyroid DiseaseRecent Weight LossRheumatismShinglesSpina BifidaStrokeThyroid DiseaseVenereal DiseaseArthritis or GoutBlood DiseaseBruise EasilyCongenital Heart ProblemsDiabetesDrug/Alcohol AddictionEmphysemaFrequent UrinationHeart MurmurHeart Valve or PacemakerHerpesHypoglycemiaLung DiseaseRheumatic FeverTuberculosisUlcers or GI ProblemsAsthmaChest PainsConvulsionsEasily WindedExcessive ThirstFrequent DiarrheaGenital HerpesHeart Attack/Heart FailureHepatitis (B or C)Low Blood PressureIrregular HeartbeatLeukemiaMitral Valve ProlapseRadiation TreatmentsRenal DiseaseScarlet FeverSickle Cell DiseaseStomach/Intestinal DiseaseSwelling of LimbsTonsillitisYellow JaundiceArtificial JointBlood TransfusionCancerCurrently PregnantDizziness or FaintingEating DisorderEpilepsy or SeizuresGlaucomaHeart TroubleHepatitis (A)HIV-AIDS-ARCJaw Joint PainPsychiatric CareSinus ProblemsTumor or GrowthX-ray/ChemotherapyNo to All Do you have any condition or problem, not listed, which we should know about? Please explain Have you ever been given antibiotics before dental treatment YesNo Have you recently consumed alcohol? YesNo Have you recently used recreational drugs? YesNo Today's Date (required)
