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Date: 8/23/2017Date of last cleaning and examCity/StateName of dentistDo 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:History of heart murmur?tooth sensitivity?Have you ever been told you may need to take antibiotics prior to dental treatment?Tobacco use? If so, what kind and how much?Unusual reaction to dental injections?NoneHistory of Knee/hip replacement? If so, when?List all medications or drugs you are now taking:Medical Doctor: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:Address:Emergency ContactPhoneRelationshipCity/State:Birthdate:First Name:Medical Historymm/dd/yyyyLast Name:Clean Smiles Dental Hygiene Practice of Claire Fleckles and Vicki Harris