Health History
Physician's Name Date of last visit
Please select "yes" or "no" to indicate if you have had any of the following?
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Women
Yes No
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Yes No
Medications
Allergies
Aspirin
Barbiturates (Sleeping pills)
Codeine
Iodine
Latex
Local Anesthetic
Penecillin
Sulfa
Other
Updates (To be filled out in future appointments)