Medical HistoryLast Name:First Name:Birthdate:Name of Medical Doctor:City/State:Emergency ContactPhoneRelationshipList all medications or drugs you are now taking:NoneList all medications or drugs you are allergic to:NoneList any medical conditions you may have including: asthma, bleeding problems, cancer, diabetes, heart murmur, heart trouble, high blood pressure, joint replacement, kidney disease, liver disease, pregnancy, psychiatric treatment, sinus trouble, stroke, ulcers, or history of rheumatic fever or of taking fen-phen:NoneTobacco use? If so, what kind and how much?Unusual reaction to dental injections?Are you in pain?New patients:Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?Do you have BiteWing x-rays that are less than 1 year old?Name of former dentistCity/StateDate of last cleaning and examDate: 10/17/2017
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