Medical History

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    AspirinPenicillinCodeineAcrylicMetalLatex RubberOther

    Women (Please Check)

    Pregnant/Trying to get pregnantNursingTaking oral contraceptives

    If yes to any of the starred* conditions, please call prior to your appointment... Pre-medication may be required.

    Heart Trouble/DiseaseHeart Murmur*Irregular HeartbeatAngina / Chest PainHeart Attack/ FailureCongenital Heart disorderMitral Valve Prolapse*Scarlet FeverRheumatic Fever*Artificial Heart Valve*Heart Pace Maker*Heart Surgery*High Blood PressureLow Blood PressureBlood DiseaseYellow JaundiceKidney ProblemsRenal DialysisVenereal DiseaseAIDSHIV PositiveGenital HerpesDrug AddictionAllergies (Medicines)Allergies (Pollen or Dust)EmphysemaTuberculosisRadiation TreatmentStomach/ Intestinal DiseaseRecent Weight LossExcessive ThirstLiver DiseaseThyroid DiseaseArthritis/ GoutRheumatismCortisone MedicineTumors or GrowthsBruise EasilyAnemiaExcessive BleedingSickle Cell DiseaseHemophiliaLeukemiaRecent Blood TransfusionSwelling of LimbsLung DiseaseBreathing ProblemShortness of BreathFrequent CoughHay FeverSinus TroubleAsthmaCold SoresFever BlistersHerpesStrokeConvulsionsEpilepsy or SeizuresFainting or DizzinessNervousnessPsychiatric CareHives or RashCancerChemotherapyUlcersFrequent DiarrheaDiabetesHypoglycemiaHepatitis A (infectious)Hepatitis B or CParathyroid diseasePain in Jaw JointsGlaucomaAlzheimer’s Disease

    Do you wish to talk to the dentist privately about any problem?

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