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Name of former dentistCity/StateDate of last cleaning and examDate: 9/22/2017Unusual reaction to dental injections?Any Unlisted Condition:Do you have BiteWing x-rays that are less than 1 year old?Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?New patients:Are you in pain?Tobacco use? If so, what kind and how much?Artificial valveHIV+/AIDSCancerAnemiaHeart attack/strokeArificial JointsPsychiatric ProblemsLeukemiaHave you ever taken Phen-fen?Radiation TherapyHeart MurmurMitral Valve ProlapseDiabetesChemotherapyHepatitisfainting/seizure/epilepsyAsthmaHigh Blood PressureYesNoNoYesYesNoDo you have or ever had any of the following diseases or medical conditions?AnestheticPenicillinTetracyclineAspirinLatexNoneList all medications or drugs you are allergic to:NoneList all medications or drugs you are now taking:RelationshipPhoneEmergency ContactCity/State:Name of Medical Doctor:Birthdate:First Name:Last Name:Medical HistoryGonorrheaSyphilisThyroid DiseaseGenital HerpesLiver DiseaseTuberculosisSickle Cell DiseaseCold Sores