Text Box: Medical History Are You Allergic To Any Of The Following? Aspirin __Yes __No Latex __Yes __No Barbiturates __Yes __No Penicillin __Yes __No Codeine __Yes __No Sedatives __Yes __No Dental Anesthetics __Yes __No Sulfa Drugs __Yes __No Erythromycin __Yes __No Tetracycline __Yes __No Jewelry/Metals __Yes __No Please List Any Additional Drugs/Materials That Cause Allergic Reactions: ____________________________________ Are You Taking Any Of The Following? Acetaminophen __Yes __No Blood Pressure Medication __Yes __No Nitroglycerin __Yes __No Antibiotics __Yes __No Cold Remedies __Yes __No Recreational Drugs __Yes __No Antihistamines __Yes __No Digitalis/Heart Medication __Yes __No Steroid/ Cortisone __Yes __No Aspirin __Yes __No Insulin/Diabetes Drugs __Yes __No Thyroid Medicine __Yes __No Blood Thinners __Yes __No Tranquilizers __Yes __No Please List Any Additional Prescription , Over-The-Counter Drugs, Herbal Remedies, Vitamins Or Mineral You Are Taking: _________________________________________________________________________________________ _______________________________________________________________________________________________ Do You Have Or Have You Experienced The Following? Abnormal Bleeding __Yes __No Herpes __Yes __No Alcohol Abuse __Yes __No High Blood Pressure __Yes __No Anemia __Yes __No HIV/AIDS __Yes __No Arthritis __Yes __No Hospitalized For Any Reason __Yes __No Artificial Bones/Joints __Yes __No Kidney Problems __Yes __No Asthma __Yes __No Liver Disease __Yes __No Blood Transfusion __Yes __No Mitral Valve Prolapse __Yes __No Cancer __Yes __No Pacemaker __Yes __No Chemotherapy __Yes __No Persistent Cough __Yes __No Chicken Pox __Yes __No Psychiatric Problems __Yes __No Colitis __Yes __No Radiation Treatment __Yes __No Congenital Heart Defect __Yes __No Rheumatic Fever __Yes __No Diabetes __Yes __No Scarlet Fever __Yes __No Difficulty Breathing __Yes __No Seizures __Yes __No Drug Abuse __Yes __No Shingles __Yes __No Emphysema __Yes __No Sinus Problems __Yes __No Epilepsy __Yes __No Steroid Therapy __Yes __No Fainting Spells __Yes __No Stroke __Yes __No Fever Blisters __Yes __No Thyroid Problems __Yes __No Glaucoma __Yes __No Tonsillitis __Yes __No Hay Fever __Yes __No Tuberculosis (TB) __Yes __No Headaches __Yes __No Ulcers __Yes __No Heart Attack __Yes __No Venereal Disease __Yes __No Heart Murmur __Yes __No Heart Surgery __Yes __No Are You Pregnant? __ Yes __ No Hemophilia __Yes __No If so, which trimester are you in? __1 __ 2 __3 Hepatitis __Yes __No Assignment Of Benefits And Financial Responsibility: The Undersigned, in requesting examination and/or treatment, authorize the release of all information (including x-rays) relating to that examination or treatment , to health service plans and insurance companies. I hereby authorize payment of dental benefits, otherwise payable to me, directly to Peters Dental Associates. I understand that I am financially responsible for any charges not paid by insurance and for all charges if my insurance claim is denied or if I do not have any insurance benefits. I agree to pay for any services rendered at the time of service unless other arrangements are made by the treatment coordinator. Patient Signature (Or Responsible Party): ______________________________________ Date: ___________________