Bleeding ProblemsLiver DiseaseCancerPregnancyDo you have any of the following medical conditions?YNKidney DiseaseYNAsthmaHeart TroubleStrokeHigh Blood PressureUlcersDiabetesPsychiatric TreatmentHeart MurmurSinus TroubleList all medications that you are now taking:Birthdate:Name of Medical Doctor:City/State:Medical History for New PatientLast Name:First Name:PhoneRelationshipEmergency ContactCodeinePenicillinIbuprofenSulfaLatexYNAnestheticAre you allergic to any of the following?YNAspirinIodineJoint ReplacementDo you have BiteWing x-rays that are less than 1 year old?Name of former dentistNew patients:Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?Date of last cleaning and examDate: 7/23/2019City/StateTobacco use? If so, what kind and how much?Rheumatic FeverReason for today`s visitAre you in pain?Unusual reaction to dental injections?
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