Registration Form

Mr. Ms.

ON

Have you ever had an unfavourable reaction after a dental treatment?

Yes No

Are you currently in pain?

Yes No

Have you ever had excessive bleeding requiring special treatment?

Yes No

Do you wear contact lenses?

Yes No

Female patients, are you or could you be pregnant or nursing?

Yes No

If pregnant, which month?

Check any of the following that you have or had in the past:  Heart trouble/Angina Asthma Cortisone treatment Liver disease Hepatitis B or C
 Stomach ulcer Arthritis Cancer treatment Hemophilia Venereal disease
 Heart murmur Lupus Psychiatric treatment Emphysema Artificial valve
 Anemia Sinus trouble Stroke Thyroid disease Addictions
 Kidney disease Diabetes Jaundice Epilepsy Cardiac pacemaker
 HIV/AIDS Nervous disorders Sickle cell disease Herpes Mitral valve prolapse
 Rheumatic fever Neck injury Migraine/Headaches Glaucoma Tuberculosis (TB)
 Fainting spells  Heart trouble/Angina Arthritis Stroke Herpes
 Stomach ulcer Lupus Jaundice Glaucoma
 Heart murmur Sinus trouble Sickle cell disease Hepatitis B or C
 Anemia Diabetes Migraine/Headaches Venereal disease
 Kidney disease Nervous disorders Liver disease Artificial valve
 HIV/AIDS Neck injury Hemophilia Addictions
 Rheumatic fever Cortisone treatment Emphysema Cardiac pacemaker
 Fainting spells Cancer treatment Thyroid disease Mitral valve prolapse
 Asthma Psychiatric treatment Epilepsy Tuberculosis (TB)  Heart trouble/Angina Diabetes Emphysema
 Stomach ulcer Nervous disorders Thyroid disease
 Heart murmur Neck injury Epilepsy
 Anemia Cortisone treatment Herpes
 Kidney disease Cancer treatment Glaucoma
 HIV/AIDS Psychiatric treatment Hepatitis B or C
 Rheumatic fever Stroke Venereal disease
 Fainting spells Jaundice Artificial valve
 Asthma Sickle cell disease Addictions
 Arthritis Migraine/Headaches Cardiac pacemaker
 Lupus Liver disease Mitral valve prolapse
 Sinus trouble Hemophilia Tuberculosis (TB)  Heart trouble/Angina
 Stomach ulcer
 Heart murmur
 Anemia
 Kidney disease
 HIV/AIDS
 Rheumatic fever
 Fainting spells
 Asthma
 Arthritis
 Lupus
 Sinus trouble
 Diabetes
 Nervous disorders
 Neck injury
 Cortisone treatment
 Cancer treatment
 Psychiatric treatment
 Stroke
 Jaundice
 Sickle cell disease
 Migraine/Headaches
 Liver disease
 Hemophilia
 Emphysema
 Thyroid disease
 Epilepsy
 Herpes
 Glaucoma
 Hepatitis B or C
 Venereal disease
 Artificial valve
 Addictions
 Cardiac pacemaker
 Mitral valve prolapse
 Tuberculosis (TB)