| Document Date: 2012-06-18 16:34:54
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MedicalCondition COLON CANCER / HEPATITIS A / LOW BLOOD PRESSURE / PAIN / PAST CANCER / PNEUMONIA / DRY EYES/GLAUCOMA / STROKE/PARALYSIS / HIVES/RASH / YES BREAST CANCER / KIDNEY DISEASE / STOMACH/INTESTINAL DISEASE / OSTEOPOROSIS / HIV/AIDS / ANGINA / RHEUMATISM/ARTHRITIS / SHORTNESS OF BREATH / HIGH BLOOD PRESSURE / COUGH / N CONGENITAL HEART DISEASE / LUPUS / LIVER DISEASE / N EMPHYSEMA / INFECTIOUS DISEASE / CURRENT CANCER / HERPES / FAINTING/DIZZINESS / TUBERCULOSIS / APNEA / ASTHMA / / MedicalTreatment RADIATION THERAPY / CHEMOTHERAPY / HEART SURGERY / / Product PENICILLIN / / Technology RADIATION / CHEMOTHERAPY / /
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Dental and Medical History Form NAME: _________________________________________________________________________________ DOB: __________________________________ 1) THE MAIN REASON FOR MY DENTAL APPOINTMENT IS: ___________