New Patient Step 8

Ultrasmile/New Patient Step 8

Are you

Presently being treated for any other illness
YesNo

Aware of a change in your general health
YesNo

taking medication for weight management (i.e. fen-phen)
YesNo

Taking dietary supplements
YesNo

Often exhausted or fatigued
YesNo

Subject to frequent headaches
YesNo

A smoker or smoked previously
YesNo

Considered a sensitive person
YesNo

Often unhappy or depressed
YesNo

FEMALE - taking birth control pills
YesNo

FEMALE – pregnant
YesNo

MALE – prostate disorders
YesNo

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