Do you consider yourself to be in good health? *

Are you now or have you been under a physician’s care within the past year? *

Do you have or have you ever had any heart or blood problems? *

Have you ever been told that you have a heart murmur? *

Do you have or have you ever had high blood pressure? *

Do you bleed or bruise easily? *

Are you subject to fainting? *

Have you ever been diagnosed as being HIV positive or having AIDS? *

Have you ever had hepatitis or liver disease? *

Have you ever had: *

Do you take any medications (including birth control pills)? *

Do you require antibiotic pre-medication for a heart condition, artificial valve, joint replacement, etc.? *

Have you ever taken Fosamax, Boniva, or any other drugs prescribed to decrease the resorption of bone as in osteoporosis or any drugs for metastatic bone cancer? *

Have you ever used or are you now using tobacco or alcohol? *

Is there any family history of substance abuse or misuse? *

Is there any personal history of substance abuse or misuse? *

Have you ever received counseling for use of alcohol and/or prescription drugs? *

Do you take any sedative medication including herbal supplements? *

Do you have any other allergies? *

Have you ever had a nervous breakdown or undergone psychiatric treatment? *

Are you now in pain? *

Do you think your teeth are impacting your general health in any way? *

Have you ever had any severe reaction to dental treatment or local anesthetics? *

Are you allergic to any local anesthetic? *

Do you have or have you ever had bleeding or sensitive gums? *