Medical History Form

Current physical health is :(Required)
Are you allergic to any of the following?

Do you have or have you experienced any of the following?

Abnormal Bleeding
Drug Abuse
Memory Loss
Acid Reflux
Emphysema
Mitral Valve Prolapse
Alcohol Abuse
Epilepsy
Occlusal Appliance
Arthritis
Glaucoma
Pacemaker
Artificial Joints
Headaches
Psychiatric Care
Artificial Valves
Heart Murmur
Radiation Treatment
Asthma
Heart Surgery
Rheumatic Fever
Blood Transfusion
Hepatitis
Sinus Problems
Cancer
HIV+/AIDS
Snoring/Sleep Apnea
Chemotherapy
High Blood Pressure
Stroke
Congenital Heart Defect
Hearing Impaired
Thyroid Problems
Depression
Kidney Problems
Tuberculosis (TB)
Diabetes
Liver Disease
Ulcers
Anxiety
High Cholesterol
Vertigo
Autism

Women :

Are you happy with the appearance of your smile?
Consent(Required)
MM slash DD slash YYYY