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Medical History
 
 
DO YOU or HAVE YOU EVER HAD: 
1.Hospitalizations for illness or injury
 
 
2. An allergic or bad reaction to any of the following: 
Asprin                               
 
Penicillin                             
 
Erythromycin                     
 
Tetracycline                       
 
Sulfa                                 
 
Local Anesthetic                 
 
Fluoride                             
Chlorhexidine (CHX)           
 
Iodine                               
 
Metals (nickel,gold,silver)   
 
Latex                                 
 
Nuts                                 
 
Fruit                                 
 
Milk                                   
 
Red Dye                             
 
Other                                 
 
 
 
3.heart problems, or cardiac stent within the last six months
 
 
4. history of infective enodarditis
 
 
5.artificial heart valve, repaired heart defect (PFO) 
 
 
6.pacemaker or implantable difibrillator
 
 
7. orthopedic or soft tissue implant (e.g joint replacement, breast implant)
 
 
 
8. high or low blood pressure
 
 
 
9. stroke (taking blood thinners)
 
 
10. anemia or other blood disorders
11. Prolonged bleeding due to a slight cut (or INR>3.5)
12. breathing problems (e.g. asthma,stuffy nose, sinus congestion) 
13. sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)
 
14.kidney disease 
 
15. liver disease or jaundice 
 
16.diabetes (Please provide your last HbA1c) 
 
16.digestive or eating disorder (e.g. celiac disease, gastric reflux, bulimia, anorexia)
 
17.osteoporosis/osteopenia or ever taken anti-resorptive medication (e.g. bisphosphonates)
 
18. autoimmune disease (rheumatoid arthritis, lupus, scleroderma)
 
19. head or neck injuries
 
20.epilepsy, convulsions (seizures) 
 
21. neurologic disorders( e.g Alzheimer's disease, dementia, prion disease)
 
22. viral infections and cold sores
23.any lumps or swelling in the mouth 
 
24. STI/STD/HPV
 
25. hepetitus Type:
 
26. HIV/AIDS
 
27. cancer
28.radiation therapy (year)
 
29. chemotherapy, immunosuppressive medication
 
30. Psychistric treatment or antidepressant medication
 
31. alcohol/recreational drug use
 
Are you: 
32. presently being treated for any other illness
 
33. a smoker, smoked previously or other (smokeless tobacco,vaping, e-cigarettes, or cannabis)
 
34. currently pregnant
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, collagen injections)
 
List all medications, supplements, vitamins, and/or probiotics
I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

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