Patient Medical History Do you have or have you had any of the following? Please check all that apply High Blood PressureHeart MurmurLiver DiseaseRadiation TherapyLow Blood PressureHeart AttackCancerRecent Weight LossEpilepsy / ConvulsionsRheumatic FeverArthritisRespiratory ProblemsLeukemiaSwollen AnklesFibromyalgiaHepatitisDiabetesFainting / SeizuresChest PainsHerpesKidney DiseaseAsthmaEasily WindedJoint Replacement or ImplantAIDS or HIV InfectionAnginaStrokeHeart DiseaseEmphysemaHay fever / AllergiesStomach Troubles / UlcersCardiac PacemakerGlaucomaTuberculosis I fully understand that I am using the services of a Denturist, not a Dentist. I understand that a Denturist does not diagnose, evaluate or treat diseases or malfunctions of the oral cavity, and I should see a dentist or physician if such services are required.
