Medical History

Please select "yes" or "no" to indicate if you have had any of the following?
Yes No
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Yes No
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Yes No
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Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
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Yes No
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Women
Yes No
Yes No
Yes No
Medications
Allergies
Aspirin
Barbiturates (Sleeping pills)
Codeine
Erythromycin
Iodine
Jewelry
Latex
Metals
Local Anesthetic
Penicillin
Tetracycline
Sulfa
Other


I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of nay changes in my medical status.