Medical Form

Have you or have you ever had any of the following conditions

Have you ever taken? :

Diet pillsAnticoagulantsTranquilizersAntidepressantCortisone

Are you allergic to or have ever had a reaction to?

Local anesthesiaPenicillinSulfonamidesOther antibioticsAspirinCodeine or other narcoticsIodineLatexOther medications If other, specify

The next 3 questions are for women:

If you are a man, answer no to all questions.

1- Are you pregnant or is there a possibility of pregnancy? *

YesNo

2- Are you nursing? *

YesNo

3- Do you take an oral contraceptive? : *

YesNo If yes, which one?

Are you currently under the care of medical specialist?*

YesNo If yes, for which medical condition?

Have you been seriously sick or hospitalised in the past 5 years? *

YesNo

Have you ever had complications after a dental or medical treatment? *

YesNo If so, describe the complication?

Do you have any inflamed or non-cured internal or external mouth injuries? *

YesNo If so, where and since when?

Do you have prostheses for any joints? *

YesNo If so, where?

Do you have an artificial cardio-vascular valve or any vascular implant? *

YesNo

Do you currently smoke or have you smoked in the past? *

YesNo