As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may
If you answer yes to any of the 4 items above, please stop and submit this form now.
Allergies. Are you allergic to or have you had a reaction to:
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended
for any other form of CHD.