Please answer every question carefully to help us plan safe dental care.
When did you have your last medical checkup?
Are you being treated for any medical condition at present, or have you been treated in the past year? * Select an answer No Yes Not sure Prefer not to answer
Details (if applicable)
Has there been any change in your general health in the past year? * Select an answer No Yes Not sure Prefer not to answer
Details (if applicable)
Are you taking any medication, non-prescription drugs or herbal supplements of any kind? * Select an answer No Yes Not sure Prefer not to answer
Details (if applicable)
Do you have any allergies? * Select an answer No Yes Not sure Prefer not to answer
Details (if applicable)
Do you have, or have you ever had, asthma? * Select an answer No Yes Not sure Prefer not to answer
Do you have, or have you ever had, any heart or blood pressure problems? * Select an answer No Yes Not sure Prefer not to answer
Details (if applicable)
Have you had a heart valve replacement or repair, heart infection, congenital heart condition or heart transplant? * Select an answer No Yes Not sure Prefer not to answer
Do you have a prosthetic or artificial joint? * Select an answer No Yes Not sure Prefer not to answer
Do you have conditions or therapies affecting your immune system (e.g. leukemia, HIV, radiotherapy or chemotherapy)? * Select an answer No Yes Not sure Prefer not to answer
Have you ever had hepatitis, jaundice or liver disease? * Select an answer No Yes Not sure Prefer not to answer
Do you have a bleeding problem or bleeding disorder? * Select an answer No Yes Not sure Prefer not to answer
Are there family medical conditions your dentist should know about? * Select an answer No Yes Not sure Prefer not to answer
Details (if applicable)
Do you smoke or chew tobacco products? * Select an answer No Yes Not sure Prefer not to answer
Are you pregnant or nursing? * Select an answer No Yes Not sure Prefer not to answer
