Your Dental Office

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Are you a Full Time/Part Time student?

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Do you have dental insurance?

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Have you ever been hospitalized or had an operation?

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Were you or are you taking any prescription or non-prescription medications or vitamins?

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Are you allergic to any prescription or non-prescription medication?

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Do you have any food allergies?

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Do you have any environmental allergies?

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Do you experience fainting, dizzy spells, nervous disorders, seizures, convulsions, or epilepsy?

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Have you ever received psychiatric treatment or had any type of mental illness?

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Have you ever experienced breathing difficulties?

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If yes, please select all that apply.

Asthma Pneumonia

Emphysema Tuberculosis

Chronic Cough

Have you ever experienced the following? Select all that apply.

May we have permission to discuss your dental treatments with your spouse, parent, etc. if necessary?

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