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Dental AnestheticsPenicillinCodeineSulfa DrugsMetalAspirinLatex
Do you have, or have you had, any of the following?
AIDS/HIV PositiveAlzheimer’s DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JoinAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsions
Cortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or seizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart Pace MakerHeart Trouble/ Disease
HemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular Heart BeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric Care
Radiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitsTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice