Emergency ContactCity/State:Name of Medical Doctor:Birthdate:First Name:Last Name:YNNYAre you allergic to any of the following?Unusual reaction to dental injections?Reason for today`s visitDate of last cleaning and examCity/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?Kidney DiseasePregnancyCancerLiver DiseaseBleeding ProblemsDiabetesHeart TroubleSinus TroubleHeart MurmurPsychiatric TreatmentMedical History for New PatientsDate: 10/25/2020Rheumatic FeverTobacco use? If so, what kind and how much?Joint ReplacementStrokeUlcersHigh Blood PressureAnestheticPenicillinAsthmaNNYYDo you have any of the following medical conditions?SulfaIbuprofenList all medications that you are now taking:RelationshipPhoneIodineAspirinLatexCodeine
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