If you are completing this form for another person, what is your relationship to that person?
Allergies
Please mark your response to indicate if you have or have not had any of the following diseases or problems.
Congenital heart disease (CHD)
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
Active Tuberculosis
Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question). Note: If you answer yes to 4 of the listed questions. Please do not continue this form and call Bluegrass Dentistry directly to setup an appointment.