In an effort to serve you better, we ask that you complete the following medical form. We will be glad to assist you with any questions you have.
NOTE: Fields marked with an asterisk (*) are required.
Are you presently being treated for any medical condition at the present or within the past year?
Was your last medical checkup within the past year?
Has there been any change in your general health in the past year?
Are you currently taking any medications or non-prescription drugs of any kind?
Have you ever been warned against using any other medications?
Have you ever taken prolonged medical or non-medical drugs?
Do you suffer from any allergies (hay fever, latex/rubber, etc)?
Allergies: Have you ever had a reaction to any of the following?*
Do you or did you smoke?
Do you drink alcoholic beverages on a regular basis?
Do you use recreational drugs? (e.g. cocain or amphetamines)
(For women only) Are you pregnant?
Do you bruise easily or have prolonged bleeding?
Have you ever fainted, had shortness of breath, or chest pains?
Are you anxious during dental treatments? (Please indicate by marking the scale)
If you are nervous, would you like us to consider additional techniques along with "freezing" to help you?
Have you ever had any serious trouble with any previous dental treatment?
Do you have or have you had any of the following conditions. Please check all that apply:*
Is there anything else we should know about your health?
Clinton Dental in Little Italy
580 College Street