Patient Medical History

    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.

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