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About the Team
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About the Team
Services
Invisalign
Testimonials
Patient Forms
Specials
Patient Forms
Medial History Update
Patient Name, Last, First, MI
Social Security Number
Birth Date
Best Phone
Email Address
------------------------ MEDICAL HISTORY-------------
Name of Physician and their specialty
What is your estimate of your general health?
Excellent
Good
Fair
Poor
Hospitalization for illness or injury
Yes
No
Allergic reaction to
aspirin, ibuprofen. acetaminophen
penicillin
erythromycin
tetracycline
codeine
local anesthetic
fluoride
metals (gold, stainless steel)
latex
none
List any medications currently taking
Check any that apply
heart problems
heart Inunnur
rheumatic fever
scarlet fever
high blood pressure
stroke
artificial prosthesis (i.e. heart valve or joints)
anemia or other blood disorder
prolonged bleeding clue to a slight cut
emphysema
tuberculosis
asthma
sinus problems
kidney disease
liver disease
jaundice
hyroid or parathyroid disease
hormone c!eficiency
high cholesterol
diabetes
stomach or duodenal ulcer
digestive disorders
arthritis
glaucoma
contact lenses
head or neck injuries
epilepsy, convulsions (seizures)
viral infections and cold' sores
any lumps or swelling in the mouth
hives, skin rash, hay fever
venereal disease
tumor, abnormal growth
radiation therapy
chemotherapy
psychiatric treatment
antidepressant medication
alcoholJ drug dependency
presently being treated for any other illness
aware of a change in your general health
takinq medication for osteoporosis/osteopaths
often exhausted or fatigued
subject to frequent headaches
a heavy smoker ("i pack or more a day)
considered a touchy person
often unhappy or depressed
easily upset or irritated
pregnant female
prostate disorders male
none
Describe any current medical treatment, Impendinq surgery, or other treatment that may possibly affect your dental treatment
List any medications, supplements, and or vitamins taken within the last two years
__________________________________________________
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