insurance information / related health care services / /
MedicalCondition
No Drug Addiction / No Low Blood Pressure / No Convulsions / No Glaucoma / No Anaphylaxis / HIV / No Easily Winded Emphysema / Heart Disorder / No Alzheimer's Disease / Tumors / No Frequent Diarrhea / Seizures / No Recent Weight Loss Hepatitis A / No Angina Arthritis/Gout / Chest Pains / No Rheumatic Fever Herpes / No Stroke Liver Disease / No Anemia / No Cancer / No Rheumatism High Blood Pressure / No Parathyroid Disease / Pain in Jaw / No Blood Disease / No Cold Sores / No Frequent Cough / No Heart Trouble/Disease / No Shingles Hypoglycemia / No Leukemia / No Epilepsy / AIDS / No Genital Herpes / No Diabetes / No Renal Dialysis Hepatitis B / Rash / No Thyroid Disease Lung Disease / No Tonsillitis Mitral Valve Prolapse / Hemophilia / No Frequent Headaches / No Heart Attack / /
MedicalTreatment
oral contraceptives / emergency treatment / /
Organization
U.S. Department of Health and Human Services / INTERNATIONAL CENTER FOR DENTAL EXCELLENCE / office of the General / /
PATIENT REGISTRATION PATIENT INFORMATION: Date: □ Mr. □ Mrs. □ Ms. □ Dr.