Heart MurmurDiabetesPsychiatric TreatmentHeart TroubleSinus TroubleLiver DiseaseKidney DiseaseBleeding ProblemsPregnancyCancerStrokeDo you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?New patients:Do you have BiteWing x-rays that are less than 1 year old?Reason for today`s visitAre you in pain?Date of last cleaning and exam
Signature will be recorded later.
Date: 11/16/2018Name of former dentistCity/StateUlcersHigh Blood PressureTobacco use? If so, what kind and how much?Rheumatic FeverUnusual reaction to dental injections?Joint ReplacementYNYNAre you allergic to any of the following?Name of Medical Doctor:City/State:Last Name:Medical History for New PatientBirthdate:First Name:RelationshipList all medications that you are now taking:Emergency ContactPhoneIbuprofenSulfaPenicillinDo you have any of the following medical conditions?AsthmaYNYNIodineAspirinAnestheticCodeineLatex