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Ervousanxious n y n pre medication antibiotic before

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Unformatted text preview: y or Seizures Y NXFainting Y NXHeadaches (Frequent) Y NXHearing Concerns Y NXHeart Attack History Y N X eart Disease/Angina H XHeart Murmur Y N Y NX Heart Surgery Y N XHeart Valve Defect Y NX Hemophilia/Blood Transfusion Y NXHepatitis (A, B, C) / Liver Disease Y N High Blood Pressure X Y N HIV+ / AIDS X Y NXKidney Disease Y NXLow Blood Pressure Y N X upus L Y N X itral Valve Prolapse M Y N X ervous/Anxious N Y N Pre- Medication (Antibiotic before Dental) X Y N Psychiatric Care X Y N X espiratory Disease R X Y N Rheumatic/Scarlet Fever Y N X hicken Pox/Shingles C Y N X exually Transmitted Disease S Y N Shortness of Breath X Y N X ickle Cell Disease S Y N X inusitis S X Y N Smoke or use tobacco Y N Stroke X Y N Thyroid Disease X Y N X uberculosis T PATIENT DENTAL HISTORY Do you currently have or have you had the following? Y N X Are your teeth sensitive to hot, cold and/or sweet Y N XFrequent fever blisters, mouth ulcers Y N XBurning of tongue and/or cracking of the corners of mouth Y NX Had permanent teeth removed (wisdom teeth) Y NX Any head, neck or jaw injuries Y NX Any popping, clicking or soreness of the jaws Y N XClench and/or grind teeth Y N XDo you wear night guards Y N XWear dentures and/or partials Y N XConcerns with teeth/fillings breaking Y N XConcerns with teeth, gums, or mouth Y N X Concerns with teeth, gums,...
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