We are grateful that our practice grows by referral. Who should we thank for referring you?
1. How would you describe your general health? ExcellentGoodFairPoor
2. Are you under the care of a doctor for any medical conditions? YesNo
If yes, please explain
3. Name and address of family doctor
4. Are you wearing a pacemaker or heart valve prosthesis or do you have a joint replacement or any other medical implant? YesNo
5. Have you ever had abnormal bleeding associated with previous extractions, surgery or trauma? YesNo
6. Are you taking any kind of medications (prescribed or non-prescribed) or drugs at this time? YesNo
7. Have you been diagnosed as having HIV, AIDS (Acquired Immune Deficiency) or ARC (Aids Related Complex)? YesNo
8. Are you pregnant? N/ANoYes How Many Months:
9. Are you allergic or have had an unusual reaction to any of the following (Please select all relevant).
If Other, Please State:
10. Do you have a history of any of the following disorders? (please select)
11. Do you currently receive, or have you ever received, occasional injections by a doctor or specialist for Osteoporosis? YesNo
12. Have you ever taken any of the following medications (Please select)
13. Is there anything else about your health we should know?
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I agree the above information is to the best of my knowledge are true and correct.
Please select Yes for Acceptance: YesNo
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