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Medical History for Dr Issac’s New Patients
First Name
Last Name
Date Of Birth
Name of medical doctor
City/State
Emergency Contact
Relationship
Phone
List of medications you are currently taking
Are you allergic to any of the following?
Anesthetic
Iodine
Aspirin
Latex
Codeine
Penicillin
Ibuprofen
Sulfa
Do you have any of the following medical conditions?
Asthma
Kidney Disease
Bleeding Problems
Liver Disease
Cancer
Pregnancy
Diabetes
Psychiatric Treatment
Heart Murmur
Sinus Problems
Heart Problems
Stroke
High Blood Pressure
Ulcers
Joint Replacement
Rheumatic Fever
Tobacco use? If so, what kind and how much?
Unusual reactions to dental injections?
Reason for your visit today?
Are you in pain?
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