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    Patient Information

    MF

    MarriedSingleDivorcedWidowed



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    Home PhoneWork PhoneCell PhoneE-MailText Msg

    Health Information

    X Artificial Heart Valves X Artificial Joints X AIDS/HIV X Asthma X Cancer X Diabetes X Diet Controlled Diabetes X Insulin Dependent Diabetes X Anemia X Epilepsy/Seizures X Emphysema
    X Fainting/Dizziness X Heart Attack X Cardiac Stent X Heart Problems X Pacemaker X Hemophilia/Bleeding Disorder X Hepatitis X High Blood Pressure X Low Blood Pressure X Tuberculosis X Arthritis/Rheumatism X Back Problems X Blood Disease X Drug/Alcohol Abuse X Cocaine Use
    X Cortisone Treatments X Glaucoma X Kidney Disease X Liver Disease X Psychiatric Care X Stroke X Thyroid Problems X Ulcer(s) X Headaches X Snore/Sleep Apnea X Venereal Disease
    X Amoxicillin Allergy X Aspirin Allergy X Codeine Allergy
    X Dental Anesthetics X Latex Allergy X Penicillin Allergy X Tetracycline Allergy X Sulfa Drug Allergy X Other Drug Allergies

    YesNo
    YesNo

    YesNo

    YesNo

    YesNo

    YesNo
    YesNo
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    YesNo


    It is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and/or treatment.

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