In Case of Emergency Notify:
Date of Birth:
3. Has there been any changes in your general health in the past year? If yes, please explain:
4. Are you taking any medications, non-prescriptive drugs, or herbal supplements of any kind?
5. Do you have any allergies? If yes, please list using the categories below.
b) Latex / Rubber products:
c) Other e.g., hay fever, foods:
6. Have you ever had a peculiar or adverse reaction to any medications or injections? If yes, please explain:
7. Do you or have you ever had asthma?
8. Do you or have you ever had a heart murmur, mitral valve prolapses or rheumatic fever?
9. Do you or have you ever had any heart or blood pressure problems?
10. Do you have a prosthetic or artificial joint?
11. Have you ever been advised by your doctor to take antibiotics before dental treatment?
12. Do you have any conditions or therapies that could affect your immune system? e.g., Leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?
13. Have you ever had hepatitis, jaundice, or liver disease?
14. Do you have a bleeding problem or disorder?
15. Have you ever been hospitalized for any illness or operations? If yes please explain.
16. Do you or have you ever had any of the follow?? Please check.
17. Are there any conditions or disease not listed above that you have or have had? If so, what?
18. Are there diseases or medical problems that run in your family?(e.g. diabetes, cancer or heart disease)
19. Do you smoke or chew tobacco?
20. Are you nervous during dental treatment?
21. For women only: Are you pregnant or breast feeding? If pregnant, what is the expected delivery date?
what is the expected delivery date?
23. If yes, for what purpose do you use cannabis?
24. For what medical condition do you use cannabis?
25. How do you usually take cannabis?
26. Have you ever had any side effects with your cannabis use? If yes, what type of side effects?
27. When did you last use cannabis?
28. In addition to cannabis, do you use any other recreational drugs?
If you are human, leave this field blank.