Patient IV Screening Form

If yes, please list using the categories below:
a. Medications      
b. latex/rubber products:     
c. other (e.g, hay fever, foods etc.)        

Is yes, How often do you use your inhaler?      

If yes, Please explain      

If so do you use a home CPAP (sleep apnea) machine?   Yes   No   

NOTE: IT IS IMPORTANT THAT ANY CHANGES IN YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE.
I, the undersigned, certify that all medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician being contacted if necessary, to obtain information that is required for my dental care.