04. |
Do you have or have you had any of the following diseases or problems? |
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05. |
Have you been tested for an allergy to Mercury in your silver mercury fillings? |
Yes No |
06. |
Is your immune system suppressed or compromised? |
Yes No |
07. |
Have you ever had anemia, low blood or thin blood? |
Yes No |
08. |
Have you ever taken medication to thin your blood? |
Yes No |
09. |
Have you ever had a blood transfusion? |
Yes No |
10. |
Do you bleed longer or bruise more easily than other people? |
Yes No |
11. |
Do you have pain in your chest upon exertion? |
Yes No |
12. |
Do you get short of breath when lying down, require more than one pillow or use a CPAP when sleeping? |
Yes No |
13. |
Have you or any member of your family ever had diabetes? |
Yes No |
14. |
Do you frequently get a dry mouth, become thirsty, or urinate more than six (6) times a day? |
Yes No |
15. |
Do you have any allergies to food, medicine, etc.? |
Yes No |
16. |
Have you been told not to take PENICILLIN or Novocain? |
Yes No |
17. |
Have you ever been treated for, or taken medication for an emotional problem or for your nerves? |
Yes No |
18. |
Have you ever had a stomach, duodenal, or peptic ulcer? |
Yes No |
19. |
Have you ever had radiation (X-ray) treatment or chemotherapy for any disease? |
Yes No |
20. |
Have you ever been given cortisone treatment? |
Yes No |
Females Only : |
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Are you taking birth control pills?
Yes No
Are you pregnant?
Yes No
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If yes, when is your expected due date?
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