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Unusual reaction to dental injections?Are you in pain?Reason for today`s visitRheumatic FeverTobacco use? If so, what kind and how much?City/StateDate: 8/23/2019Date of last cleaning and examDo you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?New patients:Name of former dentistDo you have BiteWing x-rays that are less than 1 year old?Joint ReplacementIodineAspirinNYAre you allergic to any of the following?AnestheticNYLatexSulfaIbuprofenPenicillinCodeineEmergency ContactRelationshipPhoneFirst Name:Last Name:Medical History for New PatientCity/State:Name of Medical Doctor:Birthdate:List all medications that you are now taking:Sinus TroubleHeart MurmurPsychiatric TreatmentDiabetesUlcersHigh Blood PressureStrokeHeart TroubleAsthmaNYKidney DiseaseNYDo you have any of the following medical conditions?PregnancyCancerLiver DiseaseBleeding Problems