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Medical History Form

Please fill out the following form.

Date of birth
Year
Month
Day
Do you or have you had any of the following conditions? Check all that apply.
Have you had any surgeries, major illnesses or hospitalizations?
Yes
No
Are you currently (or within the past 5 years) being treated for any medical conditions or disease not listed above?
Yes
No
Do you have a prosthetic or artificial joint?
Yes
No
Have you ever had an organ transplant or implanted medical devices (ex: stimulation devices, screws, pins, etc.)?
Yes
No
Do you smoke or chew tobacco products?
Yes
No
Do you use electronic cigarettes or a vaporizer?
Yes
No
Are you pregnant?
Yes
No
Are you breast feeding?
Yes
No
Do you have any allergies to medications?
Yes
No
Do you have any other allergies?
Yes
No
Do you have an allergy to latex?
Yes
No
Are you currently taking any medications?
Yes
No
Do you currently take any prescription blood thinners?
Yes
No
Have you ever been treated for osteoporosis?
Yes
No
Does dentistry/dental treatment cause you anxiety?
Yes
No
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