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Are you in good health? ❏ Yes ❏ No • Height Weight Are you under the care of a physician? ❏ Yes ❏ No Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? ❏ Yes ❏ No Have you had any illness, operation, or been hospitalized in the past five years? ❏ Yes ❏ No Have you ever had IV sedation or general anesthesia? ❏ Yes ❏ No Have you, or a family member, had any unusual or serious reactions to sedation? ❏ Yes ❏ No Do you have, or have you had, any of the following diseases, medical conditions, or procedures? Please provide explanation to "Yes" answers, or any other relevant information: MEDICAL HISTORY... ❏ ❏ Rheumatic fever ❏ ❏ Hypertension / high blood pressure ❏ ❏ Stroke / heart attack / angina ❏ ❏ Heart surgery / pacemaker ❏ ❏ Sinus problems ❏ ❏ Asthma ❏ ❏ Trouble climbing 1-2 flights of stairs ❏ ❏ Mental health problems ❏ ❏ Problems with immune system ❏ ❏ Delay in healing ❏ ❏ Bruise easily ❏ ❏ Abnormal / excessive bleeding ❏ ❏ Sleep apnea / do you wear a CPAP? ❏ ❏ Do you smoke? If so, # packs a day ❏ ❏ Have you ever been a smoker? ❏ ❏ Are you in recovery from drugs / alcohol? ❏ ❏ Hepatitis (A,B,C) / liver disease ❏ ❏ HIV positive ❏ ❏ Seizures / epilepsy ❏ ❏ Diabetes ❏ ❏ Kidney problems ❏ ❏ Arthritis / joint disease ❏ ❏ Joint replacement ❏ ❏ Osteoporosis / osteopenia / osteonecrosis ❏ ❏ Cancer / radiation / chemotherapy ❏ ❏ Dental anxiety

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Spring 2024 gift guide

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$500,000 Term Life Insurance ID7650836411