Health History Update

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    Patient Information

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    MarriedSingleDivorcedWidowed



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    Health Information

    Artificial Heart ValvesArtificial JointsAIDS/HIVAsthmaCancerDiabetesDiet Controlled DiabetesInsulin Dependent DiabetesAnemiaEpilepsy/SeizuresEmphysema
    Fainting/DizzinessHeart AttackCardiac StentHeart ProblemsPacemakerHemophilia/Bleeding DisorderHepatitisHigh Blood PressureLow Blood PressureTuberculosisArthritis/RheumatismBack ProblemsBlood DiseaseDrug/Alcohol AbuseCocaine Use
    Cortisone TreatmentsGlaucomaKidney DiseaseLiver DiseasePsychiatric CareStrokeThyroid ProblemsUlcer(s)HeadachesSnore/Sleep ApneaVenereal DiseaseAmoxicillin AllergyAspirin AllergyCodeine Allergy
    Dental AnestheticsLatex AllergyPenicillin AllergyTetracycline AllergySulfa Drug AllergyOther Drug Allergies

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    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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