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New Patient Information
(Form 2 of 2)​​

Medical History

Have you had any serious illnesses or operations?
Have you ever had a blood transfusion?
Do you or have you ever taken bisphosphonate medications for osteoperosis, cancer, or multiple myeloma (such as Fosamax, Actonel, Boniva, Reclast, Aredia, or Zometa)?
Are you currently under physician care?
Are you pregnant or do you think you may be?
Are you nursing?
Are you taking birth control?

Select yes if you have or have had the following:

AIDS/HIV positive
Anaphylaxis
Anemia
Arthritis
Artificial heart valves
Artficial joints
Asthma
Atopic (allegy prone)
Back problems
Blood disease
Cancer
Chemical dependency
Chemotherapy
Circulatory problems
Cortisone treatments
Cough (peristent)
Coughing up blood
Diabetes
Epilepsy
Fainting
Food allergies
Glaucoma
Headaches
Heart murmur
Heart problems
Hemophilia/abnormal bleeding
Herpes
High blood pressure
Jaw pain
Kidney disease or malfunction
Liver disease
Material allergies (latex, wool, metal, chemicals)
Mitral valve prolapse
Nervous problems
Pacemaker / heart surgery
Psychiatric care
Rapid weight gain or loss
Radiation treatment
Repiratory disease
Rheumatic fever
Scarlet fever
Shingles
Shortness of breath
Skin rash
Spina bifida
Stroke
Surgical implant
Swelling of feet or ankles
Thyroid disease or malfunction
Tobacco habit
Tonsilitis
Tuberculosis
Ulcer/colitis
Venereal disease
Hepatitis
Are you allergic to any of the following?

Authorization

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

(Form 2 of 2)

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