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Dr Patrick Piovesan D. M. D P. C. Family and Cosmetic Dentistry Medical History Name Date of Birth S.S. Number Date of Last Dental Visit Reason for this visit Have you ever had any of the following Please check YES OR NO Yes or NO AIDS or HIV Allergies Anemia Artificial Joints Asthma Blood Disease Cancer Diabetes Dizziness Epilepsy Growths Fainting Glaucoma Excessive Bleeding Hay Fever Head Injuries Heart Disease Heart Murmur Hepatitis/Jaundice High Blood Pressure Jaundice Kidney Disease...
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