SulfaDo you have any of the following medical conditions?YNYNAsthmaKidney DiseaseBleeding ProblemsLiver DiseaseCancerPregnancyDiabetesPsychiatric TreatmentHeart MurmurSinus TroubleHeart TroubleStrokeHigh Blood PressureUlcersJoint ReplacementRheumatic FeverTobacco use? If so, what kind and how much?Unusual reaction to dental injections?Reason for today`s visitAre 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: 1/18/2022
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IbuprofenPenicillinCodeineLatexAspirinIodineAnestheticYNNYAre you allergic to any of the following?List all medications that you are now taking:RelationshipPhoneEmergency ContactCity/State:Name of Medical Doctor:Birthdate:First Name:Last Name:Medical History for New Patient