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Medical Health History
Please provide current information regarding the Health and Dental History and submit to our practice.
This form is HIPAA-compliant and transmitted surely within our practice. We do not disclose Patient Health Information to any party without your written permission. Please see our website for additional HIPAA compliance and privacy policies.
PLEASE select the appropriate answer and click "Submit" at the end.
Prefer not to say
Please check all that apply to your current health status.
Joint Swelling or Arthritis
High Blood Pressure
Low Blood Pressure
Hepatitis or Liver Problems
Sickle Cell Anemia
Emotional or Sensory Issues
ADD or ADHD
Pregnant or suspect to be pregnant
Tonsils or Adenoids removed
Sinus trouble, Seasonal allergies
Any known allergies?
Please list known allergies.
Please list medications being taken.
Please list physician's name:
Please list reason for seeing physician:
Please list any illness(es), condition(s) and or operations not listed above:
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This form was created inside of Classic City Orthodontics, PC.
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