A Smile 4 U - Logan Honeycutt

Yes x no nov2013 nephrotic syndrome if yes explain for

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Unformatted text preview: 07/2013 PATIENT MEDICAL HISTORY Patients Physician: Name: _Josephine Ediale _________________________________________________ Phone #: 770-459-9378 ____________________________ Date of last physical examination: ________________ Are you currently under the care of a Physician? Yes X No Nov/2013 Nephrotic Syndrome 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, Nasoprene _______________________________________________________________________________________________________________ Y N XHave you ever taken bone loss prevention medication such as Fosamax, Actonel, or Boniva? Are you allergic to any of the following: Y NX Aspirin Y N X Amoxicillin Y N X Augmentin Y NX Biaxin Y N X Codeine Y NX Dental Anesthetics Y N XErythromycin Y N XIbuprofen Y N X Keflex Y NX Latex Y N X Metals Y NXOmnicef Y N XPenicillin Y NX Sulfa Y NX Y N X Zithromax Other if not listed: ________________________________________________________________________________________________ Do you currently have or have you had the following: Y N X DD/ADHD A Y N XAlcohol/Drug Dependency Y NXAnemia...
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