Reason for today`s visitUnusual reaction to dental injections?Are you in pain?Rheumatic FeverTobacco use? If so, what kind and how much?New patients:Date of last cleaning and exam
Signature will be recorded later.
Date: 11/30/2023Do you have BiteWing x-rays that are less than 1 year old?Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?City/StateName of former dentistJoint ReplacementNYAre you allergic to any of the following?AnestheticNYIodinePenicillinCodeineLatexAspirinPhoneEmergency ContactRelationshipFirst Name:Last Name:Medical History UpdateCity/State:Name of Medical Doctor:Birthdate:Mark any medications that you are no longer taking and add any new ones:Heart MurmurSinus TroublePsychiatric TreatmentDiabetesUlcersHigh Blood PressureStrokeHeart TroubleYDo you have any of the following medical conditions?NYNIbuprofenSulfaAsthmaPregnancyCancerLiver DiseaseKidney DiseaseBleeding Problems