1. Are you in good health?
    
2. Have you been under the care of a Physician the last 2 years?
    
3. Your physicians' name, address and phone number:
    
4. Have you serious surgery or been in the hospital the last five years?
    
5. Have you taken any medication or drugs in the last two years?
    
6. Are you allergic to (i.e. itching, rash, swelling of hands feet eyes or lips) or made sick by penicillin, aspirin, codeine, or any other drugs or medicines?
    
7. Have you had any excessive bleeding requiring special treatment?
    
8. Please circle all that apply:

   Cancer AIDS Chemotherapy Nervousness Scarlet fever Heart disease Heart surgery

   Diabetes Lung disease High blood pressure Psychiatric treatment Stroke Sinus disease Venereal Disease

   Rheumatic fever Jaw Joint Disease Headaches Asthma Tuberculosis Kidney trouble

9. Have you felt an increase in thirst recently?
    
10. Have you experienced an increase in urination frequency?
     
11. Has there been a change in appetite lately?
     
12. Have you lost or gained more than ten pounds in the last year?
     
13. Has your doctor ever said you have a cancer or tumor?
     
14. Do you have any disease, condition, or problem not listed?
     
15. Women: Are you pregnant now?
                    Are you practicing birth control?
     
16. Current Medical Problems:
     
17. Current medications:
     

To the best of my knowledge, all the preceding answers are true and correct. If I ever have any change in my health, or my medications change, I will inform the dentist at the next appointment without fail.

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