City/StateName of former dentistDo you have BiteWing x-rays that are less than 1 year old?New patients:Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?Are you in pain?Unusual reaction to dental injections?Tobacco use? If so, what kind and how much?Rheumatic FeverJoint ReplacementUlcersHigh Blood PressureStrokeHeart TroubleSinus TroubleHeart MurmurPsychiatric TreatmentDiabetesPregnancyCancerLiver DiseaseBleeding ProblemsKidney DiseaseAsthmaYNNYDo you have any of the following medical conditions?SulfaIbuprofenPenicillinCodeineLatexAspirinIodineAnestheticNNYYAre 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 PatientDate of last cleaning and examDate: 10/2/2023
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