| Are you having any pain or discomfort at this time * |
YesNo |
| Have you been a patient in the hospital during the previous two years * |
YesNo |
| Are you currently under the care of a physician * |
Yes
No |
| Are you taking any medication at the present time * |
Yes
No |
| If Yes, please list the medications and their daily dosages: |
|
| Are there any medications that you should be taking, but are not taking * |
Yes
No |
|
Are you allergic to (i. e. itching, rash, swelling, etc.) or have you ever been made sick by: |
|
Pencillin
Aspirin
Codeine
Sulfa
Acetaminophen
Lidocaine
Ibuprofen
Other
No known allergies
|
| Have you ever had any excessive bleeding requiring special treatment * |
Yes
No |
| Do you currently smoke cigarettes, pipes, or cigars * |
Yes
No |
| If Yes, would you consider a smoking cessation program |
Yes
No |
| Do you chew smokeless tobacco * |
Yes
No |
| Do you consume more than three alcoholic beverages each day * |
Yes
No |
| Do you take any over the counter medication or herbal supplements on a regular basis * |
Yes
No |
| If you are a woman, are your pregnant? * |
Yes
No
Not Applicable |
| If Yes, when are you expecting |
|
I understand that several substances, including, but not limited to, anabolic steroids, cocaine,
excessive alcohol, etc., may have dangerous, and even fatal effects, when combined with dental anesthetics.
I will always disclose any potentially significant information to Dr. Davis and his associates. |
|
|
