No Venereal Disease / No Chest Pain / No Cold Sores/Fever Blisters / B(serum)Yes No Asthma / No Arthritis/Rheumatism Tumors / No Sickle Cell Disease / No Glaucoma / No Emphysema / Disease / No Tuberculosis / No Epilepsy / Seizures / No Chronic Cough / High Blood Pressure / No Mitral Valve Prolapse / No Allergies/Hives / No Congenital Heart Disease / No Neurological Disorders / No Diabetes / No Stroke / No Hemophilia / No Fainting / /
MEDICAL HISTORY Welcome! So that we may provide you with the best possible care please complete both the dental and medical history form. All information is completely confidential. Patient Name__________________________