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Patient Form

Patient Registration

Basic Information
Dental History
Appliance (Bridge/Denture/Partial)? Yes No
Medical History
Good Health? Yes No
Serious Illness or Operations? Yes No
Blood transfusion? Yes No   Weight loss medicine? Yes No
Habits: Smoke Yes No   Drugs Yes No   Tobacco Yes No
Prolonged bleeding? Yes No
If yes: Operation Injury Extraction
Family History: Diabetes Heart Problem Tumors
Women: Pregnant Nursing Birth Control Pills
Medical Conditions
AIDS/HIV Cancer Diabetes Asthma Heart Problems High BP Thyroid
Stroke Ulcer Tuberculosis Hepatitis Kidney Disease Liver Problems Mental Disorder
Contact Information
Emergency Contact
Basic Information
Dental History
Appliance (Bridge/Denture/Partial)? Yes No
Medical History
Good Health? Yes No
Serious Illness or Operations? Yes No
Blood transfusion? Yes No   Weight loss medicine? Yes No
Habits: Smoke Yes No   Drugs Yes No   Tobacco Yes No
Prolonged bleeding? Yes No
If yes: Operation Injury Extraction
Family History: Diabetes Heart Problem Tumors
Women: Pregnant Nursing Birth Control Pills
Medical Conditions
AIDS/HIV Cancer Diabetes Asthma Heart Problems High BP Thyroid
Stroke Ulcer Tuberculosis Hepatitis Kidney Disease Liver Problems Mental Disorder
Contact Information
Emergency Contact