testform Patient's Name* First Last Email* Date of last complete physical [mm/dd/yyyy]* MM slash DD slash YYYY Name of Physician* First Last Physician's Address* Street Address City State / Province / Region ZIP / Postal Code Physician's phone number*Are you in good health?* Yes No Do you or have you had any serious illness or operation?* Have you ever been told that you require pre-medication for your dental appointments?* Yes No If so, why?(If this does not apply, please indicate not applicable or n/a)* Are you under the care of physician at the present time?* Yes No Are you taking any medication?* Yes No If so, please use medication list provided. (If this doesn't apply, please indicate n/a)* Have you ever been warned against taking any medicines/drugs? If yes, please list. (If this doesn't apply, please indicate n/a)* Are you on a special diet?* Yes No what kind? (If this doesn't apply, please indicate n/a)* Salt Restricted?* Yes No Are you allergic to latex?* Yes No Are you allergic to:* Penicillin Codeine Local Anesthetic Aspirin Other drugs Food/Colouring Dyes Metals Food Not Applicable Other?* Have you had or have you been treated for any of the following?* Rheumatic Fever Heart Murmur Heart Surgery Heart Attack Angina Pacemaker Anemia Blood Disorders High Blood Pressure Blood Transfusion Hemophilia Bleed/Bruise easily Stroke Hip/Joint Replacement Diabetes M.S Kidney/Liver Disease Mental/Nervous Disease Thyroid Disease Glaucoma Muscular Dysthrophy Jaundice Hay Fever Fainting Spells Cold Sores Ulcers Gall Bladder Tuberculosis Cancer Chemotherapy Radiation Therapy Dialysis Asthma Epilepsy Arthritis Hepatitis HIV Aids Venereal Disease Alcoholism/Drug Addition Other Not Applicable Other?* Is there a history of family disease?* Yes No If yes, please list.* Do you get chest pains on exertions?* Yes No Do your ankles swell?* Yes No Have you noticed?* Increased thirst Increased frequency of urination Unexplained weight loss Other Not Applicable Other?* women only - Are you pregnant?* Yes No Maybe Not Applicable If yes, how many months?* Are you on birth control?* Yes No Not Applicable Did you know that antibiotics reduce the effects of Birth Control Pills?* Yes No Not Applicable Patient or guardian signature*I authorize treatment of the person named above and agree to pay all fees and charges for such treatment. I acknowledge that I am responsible for informing the doctor of any changes in my health history prior to treatment. Date of Application* MM slash DD slash YYYY Δ