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Gender
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04/01/2026Click to Sign
Lung Disease
Hiatal Hernia
Other Implant
Swollen Lymph Nodes
Penicillin
Novocaine
Aspirin
Codeine
Rubber or Latex
Had Radiation Treatments
Had Chemotherapy
Pacemaker or Heart Surgery
Suspect Immonosuppression
Performed Blood Transfusion
Diabetes
Heart Disease or Chest Pain
Tubercolosis
Rheumatic Fever
Bronchitis
Prosthetic Heart Valve
Chronic Fatigue, Night Sweats, Chronic Cough, or Recurrent Mouth Sores
Stomach or Bowel Problems
Hepatitis
Oral Yeast or Fungal Infections
Alcohol or Drug Dependency
Swelling of Feet or Ankles
Unintentional Weight Loss
Glaucoma or Other Eye Problems
High or Low Blood Pressure
Blood Diseases, Anemia, or Leukemia
Cancer or Malignant Tumors
Shortness of Breath
Epilepsy or Seizure Disorder
Nitroglycerine or Chest Patch
Blood Thinners
Tranquilizers or Sedatives
Dilantin, Phenobarbital, or Seizure Medication
Digitalis or Other Heart Medicines
Insulin or Oral Diabetic Medicines
Thyroid Medications
Had Complicated Tooth Extractions
Excessive Bleeding
Using Blood Thinners
Medication or Surgery Affecting Immune System
Do you or have you ever smoked tobacco products?(including e-cigarettes, vapes)
Do you or have you ever used tobacco products, if yes
Do you or have you ever used tobacco products, how often?
Do you drink alcohol?
Alcohol drinking level
Do you or have you ever used recreation drugs?
Venereal or Sexually Transmitted Disease
Heart Valve Damage or Murmur
Hemophilia
Kidney Disease
Kidney Disease or Transplant
Liver Disease
Chronic Diarrhea
Osteoporosis or Other Bone Disease
Fainting or Dizziness
Strokes or Heart Attack
Recurrent Earache or Other Ear Pain
TMJ
Steroids
Birth Control Pills or Hormone Supplements
Pregnant
Breastfeeding
Seek Pregnancy Confirmation First
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04/01/2026Click to Sign
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