Patient Forms Please click here to print your medical history to complete and bring to the office. You can also fill in the following Health History Form online: Your Name (required) Date Are you in good health? Yes No Has there been any change in your general health in the last year? Yes No Date of last physical exam? Are you now under a physician's care for a particular problem? Yes No Have you ever had any serious illnesses, operations, or hospitalizations? Yes No If so, please describe. Height Weight DO YOU HAVE OR HAVE YOU EVER HAD: Rheumatic Fever or Rheumatic Heart Disease Yes No Congenital Heart Disease Yes No Cardiovascular Disease (Heart Attack, Heart Trouble, Heart Murmur, Coronary Artery Disease, Angina, High Blood Pressure, Stroke, Palpitations, Heart Surgery, Pacemaker Yes No Lung Disease (Asthma, Emphysema, Asthma, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Chest Pain, Severe Coughing Yes No Seizures, Convulsions, Epilepsy, Fainting, or Dizziness Yes No Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion? Do you bleed easily? Yes No Liver Disease (Jaundice, Hepatitis) Yes No Kidney Disease Yes No Diabetes Yes No Thyroid Disease (goiter) Yes No Arthritis Yes No Stomach Ulcers, Colitis, or Acid Reflex Yes No Glaucoma Yes No Implants placed anywhere in your body (Heart Valve, Pacemaker, Hip, Knee) Yes No Radiation (X-Ray) Treatment for Cancer Yes No Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grinding or clenching teeth Yes No Sinus or Nasal Problems Yes No Any disease, drug, or transplant operation that has depressed your immune system? Yes No Have you been told you snore loudly or have you been diagnosed with obstructive sleep apnea? Yes No ARE YOU USING ANY OF THE FOLLOWING? Anticoagulants (Blood Thinners) Yes No Aspirin or drugs such as Motrin, Aleve, Ibuprofen? Yes No Steroids (Cortisone, etc.) Yes No Tranquilizers Yes No Insulin or Oral Anti-Diabetic drugs Yes No Digitalis, Inderal, Nitroglycerin, or other heart drugs Yes No Have you used any street drugs? Yes No Please list any and all medications taken, including prescription medications, over-the-counter medications, herbal or holistic remedies, vitamins, or minerals: Are you using or have you ever used bisphosphonates (bone density medications), such as Fosamax, Bonita, Actonel, Evista, or Novartis? Yes No Are you using or have you ever used chemotherapy medications, such as IV Aredia or Zometa? Yes No Are you using or have you ever used erectile dysfunction medications, such as Viagra, Levitra, or Cialis? Yes No ARE YOU ALLERGIC TO ANY PRESCRIPTION OR OVER THE COUNTER DRUGS, FOODS, OR SUPPLEMENTS? PLEASE LIST. Do you smoke or chew tobacco? Yes No If so, how much? Is there any past history of alcohol or chemical dependency or emotional disorder that may affect the care we provide you? Yes No How much alcohol do you drink? Have you or an immediate family member had any problem associated with intravenous anesthesia such as malignant hyperthermia? Yes No Do you have any disease, condition, or problem not listed above that you think the doctor should know about? Yes No Do you wish to talk to the doctor privately about anything? Yes No Parents, Would you like the procedure risks discussed without your minor child present? Yes No For women only: Last cycle: Are you pregnant, or is there any chance you could be pregnant? Yes No Are you nursing? Yes No If you are using oral contraceptives, it is important that you understand that antibiotics, and some other medications, may interfere with the effectiveness of oral contraceptives. Therefore, after the course of antibiotics or other medication is completed, you will need to use mechanical forms of birth control for one complete cycle of birth control pills. Please consult with your physician for further guidance. Who is your physician? Who is your dentist? Preferred Pharmacy? I understand the importance of a truthful health history in providing the best care possible. I certify that I have read and I understand the questions above. I acknowledge that I have had the opportunity to discuss my health history. My questions, if any, about the inquiries set forth have been answered to my satisfaction. I will not hold my doctor, or any other member of his staff, responsible for any errors or omissions that I have made in the completion of this form. I authorize my surgeon and his designated staff to perform an oral and maxillofacial examination for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, authorize the release of any information the course of my examination and treatment.