Fainting or SeizuresAnemiaAllergiesHigh Blood PressureTuberculosisDo you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?Congenital Heart ProblemsSinus TroubleNew patients:Are you in pain?Unusual reaction to dental injections?Tobacco use? If so, what kind and how much?Please check any conditions that you have:NoneList all medications or drugs you are allergic to:NoneRelationshipPhoneList all medications or drugs you are now taking:Emergency ContactCity/State:Name of Medical Doctor:Medical HistoryDo you have BiteWing x-rays that are less than 1 year old?Name of former dentistCity/StateDate of last cleaning and exam
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Date: 9/22/2017Rheumatic FeverHeart DiseaseMitral Valve ProlapseAsthmaLiver DiseaseDiabetesArthritis, Inflammatory RheumatismUlcersAre you in good health?Any changes in you health in last year?Any condition we should know about?
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Sexually Transmitted DiseasesKidneyTroublesMenstrual ProblemsTMJ ProblemsAre You Pregnant?DR. initFirst Name:Last Name:DOB