Unexplained weight lossOften exhausted or fatiguedArtificial Heart ValveLumps or swelling in the mouthDescribe any current medical treatment, impending surgery, genetic/development delay, or other treatment thay may possibly affect your dental treatment.Osteoporosis (list medications)Hepatitis TypeSTI/STD/HPVViral Infection/Cold SoresShortness of BreathHead or Neck InjuriesPacemakerRadiation TherapyArthritisBreathing or Sleep ProblemsAnemiaAutoimmune DiseaseTumor, abnormal growthChemical Dependency Type-HIV/AIDSThyroid DiseaseLow Blood PressureMedical History for New PatientPsychiatric TreatmentHeart MurmurSinus TroubleHeart Trouble/ProblemsDiabetes Type-Bleeding Problems (prolonged)Liver DiseaseCancer Type-PregnancyKidney DiseaseNeurologic Disorders (ADD/ADHD, etc)Cognitive DisordersAnxietyChemotherapyHeadachesHigh Blood PressureUlcersStrokeJoint Replacement (hip/knee, etc)Rheumatic Fever/Scarlet FeverDate: 2/27/2024Are 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 (one per line):Other allergySulfaDo you have any of the following medical conditions?YNYNAsthmaPenicillinAnesthetic/EpinephrineIodineAspirinLatexCodeine
Signature will be recorded later.