Please complete: Patient History Questionnaire Name & Surname * Email * Phone * HISTORY Do you have any allergies to any medications, and if so, what? * Are you currently taking any medications prescribed by a doctor? If so, what? * Do you take any over-the-counter drugs on a regular basis, and if so, what? * Have you ever needed to take antibiotics prior to any dental work? * Yes No Has any family member ever had any severe reaction to medication prescribed by a doctor? * Have you had any surgical procedures whatsoever to your head or neck, and if so, what? * Do you form unsightly scarring with cuts or scratches? * Have you ever had any of the following medical conditions? (Tick if YES) * Rashes Diabetes Asthma Liver Disease Shortness of Breath Kidney Disease Irregular Heartbeat Hepatitis High Blood Pressure Jaundice Low Blood Pressure Stroke Chest Pain Convulsion Heart Attack Anabolic Steroids Rheumatic Fever Fainted Before Heart Murmur Stomach Ulcer Severe Headaches Bruise Easily None If you are human, leave this field blank. Submit
