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Have you ever taken any of the drugs collectively referred to as "fen-phen?". These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondrmin (fenfluramine) and Redux (dextenfluramine). YesNo
Check if you have any of the following: Emphysema yes  No Radiation Treatment yes No
Anemia yes No Epilepsy yes  No Respiratory Disease yes No
Arthritis, Rheumatism yes No Fainting or dizziness yes  No Rheumatic Fever yes No
Artificial Heart Valves yes No Glaucoma yes  No Scarlet Fever yes No
Artificial Joints yes No Headaches yes  No Shortness of Breath yes No
Asthma yes No Heart Murmur yes  No Sinus Trouble yes No
Back Problems yes No Heart Problems yes  No Skin Rash yes No
Bleeding abnormally, with extractions or surgery yes No Hepatitis Type_____ yes  No Stroke yes No
Blood Disease yes No Herpes yes  No Swelling of Feet or Ankles yes No
Cancer yes No High Blood Pressure yes  No Swollen neck glands yes No
Chemotherapy yes No Jaundice yes  No Thyroid Problems yes No
Circulatory Problems yes No Kidney Disease yes  No Tonsillitis yes No
Congenital Heart Lesions yes No Liver Disease yes  No Tuberculosis yes No
Cortisone Treatments yes No Low Blood Pressure yes  No Tumor or growth on head or neck yes No
Cough, persistent or bloody yes No Mitral Valve Prolapse yes  No Ulcer yes No
Diabetes yes No Nervous Problems yes  No Venereal Disease yes No
Do you Wear Contact Lenses? yes No Pacemaker yes  No Weight Loss, unexplained yes No
Psychiatric Care yes  No AIDS/HIV yes No
Women
Are you Pregnant? yes No Due Date___________________ Taking birth control pills? yes No
MEDICATIONS ALLERGIES
List medications you are taking and the correlating diagnosis: Aspirin
Local Anesthetic
______________________________________ Barbiturates(Sleeping Pills)
Penicillin
______________________________________ Codeine
Sulfa
______________________________________ Iodine
Other______________
______________________________________ Latex_________________
___________________
Pharmacy Name__________________________ Phone(____)_______________________________
UPDATES (to be filled in at future appointments)
Has there been any change in your health since your last dental appointment? yes  No
For what conditions? _________________________________________________________________
Are you taking any new medications? _________If so, what___________________________________________
Patient's Signature___________________________________________
Doctor's Signature___________________________________________
----------------------------------------------------------------------------------------------------
Has there been any change in your health since your last dental appointment? yes  No
For what conditions? _________________________________________________________________
Are you taking any new medications? _________If so, what___________________________________________
Patient's Signature___________________________________________
Doctor's Signature___________________________________________
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