• Health History

  • Are you in good health?*
  • Date of last physical?*
     / /
  • Any change in your general health within the past year?*
  • Are you undergoing any treatment at this time? YESNO If yes, for what condition?*
  • Are you taking any drugs or medication?*
  • Are you using or have used any recreational drugs?*
  • Are you taking any over the counter drugs?*
  • Are you sensitive or allergic to any medications, foods, metal, or materials?*
  • Are you taking any blood thinners?*
  • Do you have a pacemaker?*
  • Are you pregnant?*
  • Taking medication for osteoporosis?*
  • Are you a smoker or former smoker?*
  • Do you chew tobacco?*

  • Do you have or have you had any of the following:

  • Hospitalization for illness or injury*
  • TMJ/TMD*
  • Scarlet Fever*
  • Artificial Heart Valve*
  • Back problems*
  • Rheumatic Fever*
  • Heart Ailments*
  • Frequent headaches*
  • Sinus trouble*
  • Heart murmur*
  • Epilepsy/Seizures*
  • Tumors/Abnormal growths*
  • Congenital Heart Disease*
  • Fainting Spells*
  • Bumps or swelling in mouth*
  • A Stroke*
  • Glaucoma*
  • Stomach ulcer*
  • High Blood Pressure*
  • Steroid Therapy*
  • Digestive disorders Ulcers*
  • Low Blood Pressure*
  • Hormone deficiency*
  • Colitis*
  • Blood disorder*
  • Thyroid problems*
  • Radiation/Chemotherapy*
  • Anemia*
  • Tonsillitis*
  • Cancer*
  • Sickle Cell*
  • Tuberculosis*
  • Liver Disease*
  • Prolonged bleeding to slight cut*
  • Lime Disease*
  • Hepatitis (Type __)*
  • High Cholesterol*
  • Herpes (Type __)*
  • Alcohol abuse*
  • Kidney Disease*
  • Cold Sores*
  • Drug abuse*
  • Diabetes (Type __)*
  • Shingles*
  • Psychiatric treatment*
  • Asthma*
  • Hay Fever Hives/*
  • Emotional problems*
  • Emphysema*
  • Rash HIV/AIDS*
  • Anti-depressant meds*
  • Head/Neck injuries*
  • Venereal Disease*
  • Neurological problems*
  • Date:*
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  • Date:*
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  • Should be Empty: