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MEDICAL HISTORY QUES NAIRE <br /> Name: Date: <br /> Emergency Contact: Phone: <br /> Please check any conditions listed below that may apply to you: Current or Past <br /> Diabetes <br /> Epilepsy <br /> Chronic Fainting <br /> Heart Condition or irregularities <br /> High or Low Blood Pressure <br /> Hemophilia <br /> Herpes <br /> Hepatitis AB, or C <br /> HIV or AIDS <br /> Severe Sinus issues <br /> Eczema or Psoriasis <br /> Keloid Scarring <br /> Pregnant or Nursing <br /> Severe Anxiety or Clinical Depression <br /> other psychological disorders <br /> Do you have any allergies? <br /> Are you on any medication? <br /> Do you have any other current medical conditions that may affect the healing process of your procedure? <br /> How long has it been since you last ate or drank anything? <br /> Have you ever been prescribed antibiotics prior to a dental or surgical procedure?If so,why? <br /> Is it necessary for you to obtain extra numbing injections prior to a dental procedure? <br /> Is there any other information you feel is pertinent for the outcome of this procedure? <br /> The information I have provided is complete and true to the best of my knowledge: <br /> Signature: <br />