Existing Patient Health History Step 1 of 6 16% PERSONAL INFORMATIONPatient Name First Last Preferred Email Address HEALTH HISTORYDo you have, or have you had any of the following conditions? (Please check all that apply) Are you required to Pre-medicate before dental treatment? Blood Problems (Anemia) Blood transfusion Heart problems Heart murmur, mitral valve prolapse, heart defect Heart Pacemaker Stroke Bone or joint problems Artificial joints or valves High blood pressure Low blood pressure Tuberculosis or other lung problems Kidney disease Hepatitis, jaundice or other liver disease Diabetes TYPE 1 or TYPE 2 Epilepsy or Neurological disorders Thyroid problems Arthritis Herpes or cold sores AIDS or HIV Cancer or Tumor Abnormally heavy bleeding after any surgery Hayfever or sinus trouble Allergies Asthma Other (please specify) HEALTH HISTORYAre you allergic to, or have you reacted adversely to any of the following? Latex Penicillin or other antibiotics Local anesthetics Codeine or other narcotics Sulfa drugs Barbiturates, sedatives, or sleeping pills Aspirin Other (please specify) HEALTH HISTORYAre you taking any of the following? Aspirin Anticoagulants (blood thinners e.g., Coumadin) Local anesthetics Antibiotics or sulfa drugs High blood pressure medicine Antidepressants or tranquilizers Insulin other diabetes drugs Nitroglycerin Cortisone or other steroids Osteoporosis (bone density) medicine Natural supplements Other (please specify) HEALTH HISTORYDo you smoke, vape or use tobacco?YesNoFemale patients, please check all that apply Are you pregnant or plan to become pregnant Are you taking hormones or contraceptives Name of your primary medical physician Primary medical physician contact (phone or email) By providing my signature below, I certify that all the information (including medical, personal, and insurance records) is true and complete. I give my full permission to Prestige Dental to check and verify my credit and/or employment history. I further understand that Prestige Dental will assist me in filing my claims, but the insurance coverage I have for dental services can vary and will depend on my insurance plan. I understand that I am responsible for all fees and services. Because Prestige Dental personnel often provide continuing education to other doctors, I give my permission to use my photos for educational purposes. If the patient is a minor, as the responsible party I give permission, in my absence, to provide examinations, dental cleanings and necessary x-rays as part of routine care for this patient. Signature*Date MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.