A Smile 4 U - Jordan Diaz

Yes no are you pregnant yes no due date are

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Unformatted text preview: e: __________________________________________________ Phone #: ____________________________ Date of last physical examination: ________________ Are you currently under the care of a Physician? YesX No NOV. 2013 Asthma / Allergies If Yes Explain: _______________________________________ For Women: Are you taking birth control pills? Yes No / Are you pregnant? Yes No - Due Date: ________ / Are you nursing? Yes No Please list current prescription medications: _Claratin / Albuterol ______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Y N x Have you ever taken bone loss prevention medication such as Fosamax, Actonel, or Boniva? Are you allergic to any of the following: Y N X Aspirin Y NX Amoxicillin Y N X Augmentin Y NX Biaxin Y NX Codeine Y N XDental Anesthetics Y N X Erythromycin Y N X Ibuprofen Y N X Keflex Y N X Latex Y NX Metals Y NX Omnicef Y N X Penicillin Y N X Sulfa Y NX Y NX Zithromax Other if not listed: ________________________________________________________________________________________________ Do you currently have or have you had the following: Y NXADD/ADHD Y N X lcohol/Drug Dependency A Y NXAnemia Y NXAnorexia/Bulimia Y NXArtificial Joint(s) (hip/knee) X Y N Asthma Y NXBleeding Abnormally with Extraction Y N XBlood Disease Y NXCardiac Pacemaker Y N X ancer / Chemotherapy / Radiation Treatment C Y N XCongenital Heart Defect Y NXContact Lenses Y NXCough (Chronic) Y NXCold Sores/Fever Blisters Y NXDiabetes Y N XEmphysema Y NXEnvironmental Allergies Y NXEpileps...
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