Elite Smiles Dentistry

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Are you under the care of a physician?

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Are you taking any medicine or drugs?

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Have you been hospitalized in the last 5 years?

YesNo

Are you allergic to anything (drugs, food)?

YesNo

Have you had or have any of the following?

Heart Trouble

Rheumatic Fever

Diabetes

Heart Murmur

High Blood Pressure

Liver Disease

Epilepsy

Cancer

Tuberculosis Heart Trouble

Rheumatic Fever

Diabetes

Heart Murmur

High Blood Pressure

Liver Disease

Epilepsy

Cancer

Tuberculosis

Anemia

Blood Disease

Asthma

A.i.d.s Anemia

Blood Disease

Asthma

A.i.d.s

Do you smoke? Packs per day

Are you pregnant?

I understand that I am responsible for charges on services rendered to me.

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