Medical History for New PatientPsychiatric TreatmentHeart MurmurSinus TroubleHeart TroubleDiabetesBleeding ProblemsLiver DiseaseCancerPregnancyKidney DiseaseAre 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 examReason for today`s visitUnusual reaction to dental injections?High Blood PressureUlcersStrokeJoint ReplacementRheumatic FeverTobacco use? If so, what kind and how much?Date: 11/16/2018Are you allergic to any of the following?YNYNLast Name:First Name:Birthdate:Name of Medical Doctor:City/State:Emergency ContactPhoneRelationshipList all medications that you are now taking:IbuprofenSulfaDo you have any of the following medical conditions?YNYNAsthmaPenicillinAnestheticIodineAspirinLatexCodeine
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