false
16
Medical History
MedicalHistory
10
Microsoft Sans Serif
850
1400
false
false
12074
16
InputField
misc
10
Microsoft Sans Serif
false
427
1044
302
18
None
false
116
false
12073
16
InputField
misc
10
Microsoft Sans Serif
false
385
1023
250
18
None
false
115
false
12071
16
InputField
misc
10
Microsoft Sans Serif
false
471
939
100
18
None
false
114
false
12072
16
InputField
misc
10
Microsoft Sans Serif
false
603
984
154
18
None
false
114
false
12070
16
InputField
misc
10
Microsoft Sans Serif
false
193
939
100
18
None
false
114
false
12069
16
InputField
misc
10
Microsoft Sans Serif
false
242
984
250
18
None
false
113
false
12067
16
CheckBox
problem:Other
0
false
435
914
11
11
None
N
false
111
false
12068
16
InputField
misc
10
Microsoft Sans Serif
false
307
964
400
18
None
false
112
false
12066
16
CheckBox
problem:Other
0
false
414
914
11
11
None
Y
false
110
false
12065
16
CheckBox
problem:Psychiatric Care
0
false
435
893
11
11
None
N
false
109
false
12064
16
CheckBox
problem:Psychiatric Care
0
false
414
893
11
11
None
Y
false
108
false
12063
16
CheckBox
problem:Back Problems
0
false
435
871
11
11
None
N
false
107
false
12062
16
CheckBox
problem:Back Problems
0
false
414
871
11
11
None
Y
false
106
false
12061
16
CheckBox
problem:Osteoarthritis
0
false
435
849
11
11
None
N
false
105
false
12060
16
CheckBox
problem:Osteoarthritis
0
false
414
849
11
11
None
Y
false
104
false
12059
16
CheckBox
problem:Skin Disease
0
false
435
827
11
11
None
N
false
103
false
12058
16
CheckBox
problem:Skin Disease
0
false
414
827
11
11
None
Y
false
102
false
12057
16
CheckBox
problem:Hypothyroidism
0
false
435
805
11
11
None
N
false
101
false
12056
16
CheckBox
problem:Hypothyroidism
0
false
414
805
11
11
None
Y
false
100
false
12055
16
CheckBox
problem:Anesthesia Problems
0
false
435
783
11
11
None
N
false
99
false
12054
16
CheckBox
problem:Anesthesia Problems
0
false
414
783
11
11
None
Y
false
98
false
12053
16
CheckBox
problem:Sleep Apnea
0
false
435
760
11
11
None
N
false
97
false
12052
16
CheckBox
problem:Sleep Apnea
0
false
414
760
11
11
None
Y
false
96
false
12051
16
CheckBox
problem:Rheumatic Heart Disease
0
false
435
739
11
11
None
N
false
95
false
12050
16
CheckBox
problem:Rheumatic Heart Disease
0
false
414
739
11
11
None
Y
false
94
false
12049
16
CheckBox
problem:Gastric Ulcer
0
false
435
717
11
11
None
N
false
93
false
12048
16
CheckBox
problem:Gastric Ulcer
0
false
414
717
11
11
None
Y
false
92
false
12047
16
CheckBox
problem:Stroke
0
false
435
695
11
11
None
N
false
91
false
12045
16
CheckBox
problem:Sinus Problems
0
false
435
673
11
11
None
N
false
89
false
12046
16
CheckBox
problem:Stroke
0
false
414
695
11
11
None
Y
false
90
false
12044
16
CheckBox
problem:Sinus Problems
0
false
414
673
11
11
None
Y
false
88
false
12043
16
CheckBox
problem:Hepatitis
0
false
435
650
11
11
None
N
false
87
false
12042
16
CheckBox
problem:Hepatitis
0
false
414
650
11
11
None
Y
false
86
false
12040
16
CheckBox
problem:Liver Disease
0
false
414
629
11
11
None
Y
false
84
false
12041
16
CheckBox
problem:Liver Disease
0
false
435
629
11
11
None
N
false
85
false
12039
16
CheckBox
problem:Renal Failure
0
false
435
607
11
11
None
N
false
83
false
12038
16
CheckBox
problem:Renal Failure
0
false
414
607
11
11
None
Y
false
82
false
12037
16
CheckBox
problem:Renal Disease
0
false
435
585
11
11
None
N
false
81
false
12036
16
CheckBox
problem:Renal Disease
0
false
414
585
11
11
None
Y
false
80
false
12035
16
CheckBox
problem:Pregnancy
0
false
99
915
11
11
None
N
false
79
false
12034
16
CheckBox
problem:Pregnancy
0
false
78
915
11
11
None
Y
false
78
false
12033
16
CheckBox
problem:Radiation Therapy
0
false
98
894
11
11
None
N
false
77
false
12032
16
CheckBox
problem:Radiation Therapy
0
false
77
894
11
11
None
Y
false
76
false
12031
16
CheckBox
problem:Pacemaker/Defibrillator
0
false
98
871
11
11
None
N
false
75
false
12030
16
CheckBox
problem:Pacemaker/Defibrillator
0
false
77
872
11
11
None
Y
false
74
false
12029
16
CheckBox
problem:Smokes Drugs
0
false
98
850
11
11
None
N
false
73
false
12028
16
CheckBox
problem:Smokes Drugs
0
false
77
850
11
11
None
Y
false
72
false
12026
16
CheckBox
problem:Smoker
0
false
77
828
11
11
None
Y
false
70
false
12027
16
CheckBox
problem:Smoker
0
false
98
828
11
11
None
N
false
71
false
12025
16
CheckBox
problem:COPD / Emphysema
0
false
98
806
11
11
None
N
false
69
false
12023
16
CheckBox
problem:Arrhythmia
0
false
98
784
11
11
None
N
false
67
false
12024
16
CheckBox
problem:COPD / Emphysema
0
false
77
806
11
11
None
Y
false
68
false
12022
16
CheckBox
problem:Arrhythmia
0
false
77
784
11
11
None
Y
false
66
false
12021
16
CheckBox
problem:Artificial Heart Valves
0
false
98
762
11
11
None
N
false
65
false
12020
16
CheckBox
problem:Artificial Heart Valves
0
false
77
762
11
11
None
Y
false
64
false
12019
16
CheckBox
problem:Congestive Heart Failure
0
false
98
739
11
11
None
N
false
63
false
12018
16
CheckBox
problem:Congestive Heart Failure
0
false
77
739
11
11
None
Y
false
62
false
12017
16
CheckBox
problem:Hypertension
0
false
98
717
11
11
None
N
false
61
false
12016
16
CheckBox
problem:Hypertension
0
false
77
717
11
11
None
Y
false
60
false
12015
16
CheckBox
problem:Myocardial Infarction
0
false
98
695
11
11
None
N
false
59
false
12014
16
CheckBox
problem:Myocardial Infarction
0
false
77
695
11
11
None
Y
false
58
false
12013
16
CheckBox
problem:Heart Murmur
0
false
98
673
11
11
None
N
false
57
false
12012
16
CheckBox
problem:Heart Murmur
0
false
77
673
11
11
None
Y
false
56
false
12011
16
CheckBox
problem:Diabetes
0
false
98
651
11
11
None
N
false
55
false
12010
16
CheckBox
problem:Diabetes
0
false
77
651
11
11
None
Y
false
54
false
12009
16
CheckBox
problem:Cancer
0
false
98
629
11
11
None
N
false
53
false
12008
16
CheckBox
problem:Cancer
0
false
77
629
11
11
None
Y
false
52
false
12007
16
CheckBox
problem:Coagulopathy
0
false
98
607
11
11
None
N
false
51
false
12006
16
CheckBox
problem:Coagulopathy
0
false
77
607
11
11
None
Y
false
50
false
12005
16
CheckBox
problem:Asthma
0
false
98
585
11
11
None
N
false
49
false
12004
16
CheckBox
problem:Asthma
0
false
77
585
11
11
None
Y
false
48
false
12003
16
CheckBox
allergy:Other Food/Environmental Allergy
0
false
417
498
11
11
None
Y
false
47
false
12002
16
CheckBox
allergy:Other Food/Environmental Allergy
0
false
438
498
11
11
None
N
false
47
false
12001
16
CheckBox
allergy:Other Drug Allergy
0
false
437
475
11
11
None
N
false
47
false
12000
16
CheckBox
allergy:Other Drug Allergy
0
false
416
475
11
11
None
Y
false
46
false
11999
16
CheckBox
allergy:Cephalosporins
0
false
437
453
11
11
None
N
false
45
false
11998
16
CheckBox
allergy:Cephalosporins
0
false
416
453
11
11
None
Y
false
44
false
11997
16
CheckBox
allergy:Morphine
0
false
437
431
11
11
None
N
false
43
false
11996
16
CheckBox
allergy:Morphine
0
false
416
431
11
11
None
Y
false
42
false
11994
16
CheckBox
allergy:Sulfa / Bactrim
0
false
416
409
11
11
None
Y
false
40
false
11995
16
CheckBox
allergy:Sulfa / Bactrim
0
false
437
409
11
11
None
N
false
41
false
11993
16
CheckBox
allergy:Penicillin / Amoxicillin
0
false
437
387
11
11
None
N
false
39
false
11992
16
CheckBox
allergy:Penicillin / Amoxicillin
0
false
416
387
11
11
None
Y
false
38
false
11991
16
CheckBox
allergy:Latex
0
false
437
365
11
11
None
N
false
37
false
11990
16
CheckBox
allergy:Latex
0
false
416
365
11
11
None
Y
false
36
false
11989
16
CheckBox
allergy:Iodine
0
false
437
343
11
11
None
N
false
35
false
11988
16
CheckBox
allergy:Iodine
0
false
416
343
11
11
None
Y
false
34
false
11987
16
CheckBox
allergy:Ibuprofen
0
false
437
320
11
11
None
N
false
33
false
11986
16
CheckBox
allergy:Ibuprofen
0
false
416
320
11
11
None
Y
false
32
false
11985
16
CheckBox
allergy:Codeine
0
false
437
298
11
11
None
N
false
31
false
11983
16
CheckBox
allergy:Aspirin
0
false
437
276
11
11
None
N
false
29
false
11984
16
CheckBox
allergy:Codeine
0
false
416
298
11
11
None
Y
false
30
false
11982
16
CheckBox
allergy:Aspirin
0
false
416
276
11
11
None
Y
false
28
false
11979
16
CheckBox
allergy:None
0
false
655
183
11
11
None
N
false
25
false
11981
16
CheckBox
allergy:Local Anesthetics
0
false
437
254
11
11
None
N
false
27
false
11980
16
CheckBox
allergy:Local Anesthetics
0
false
416
254
11
11
None
Y
false
26
false
11978
16
CheckBox
allergy:None
0
false
603
183
11
11
None
Y
false
24
false
11977
16
InputField
inputMed15
10
Microsoft Sans Serif
false
75
514
327
18
None
false
23
false
11976
16
InputField
inputMed14
10
Microsoft Sans Serif
false
75
492
327
18
None
false
22
false
11975
16
InputField
inputMed13
10
Microsoft Sans Serif
false
75
470
327
18
None
false
21
false
11974
16
InputField
inputMed12
10
Microsoft Sans Serif
false
75
448
327
18
None
false
20
false
11973
16
InputField
inputMed11
10
Microsoft Sans Serif
false
75
426
327
18
None
false
19
false
11972
16
InputField
inputMed10
10
Microsoft Sans Serif
false
76
402
327
18
None
false
18
false
11971
16
InputField
inputMed9
10
Microsoft Sans Serif
false
75
380
327
18
None
false
17
false
11970
16
InputField
inputMed8
10
Microsoft Sans Serif
false
75
358
327
18
None
false
16
false
11968
16
InputField
inputMed6
10
Microsoft Sans Serif
false
75
314
327
18
None
false
14
false
11969
16
InputField
inputMed7
10
Microsoft Sans Serif
false
75
336
327
18
None
false
15
false
11966
16
InputField
inputMed4
10
Microsoft Sans Serif
false
75
270
327
18
None
false
12
false
11967
16
InputField
inputMed5
10
Microsoft Sans Serif
false
75
292
327
18
None
false
13
false
11962
16
InputField
misc
10
Microsoft Sans Serif
false
570
145
187
18
None
false
8
false
11963
16
InputField
inputMed1
10
Microsoft Sans Serif
false
75
204
327
18
None
false
9
false
11965
16
InputField
inputMed3
10
Microsoft Sans Serif
false
75
248
327
18
None
false
11
false
11964
16
InputField
inputMed2
10
Microsoft Sans Serif
false
74
226
327
18
None
false
10
false
11961
16
InputField
misc
10
Microsoft Sans Serif
false
386
145
99
18
None
false
7
false
11960
16
InputField
misc
10
Microsoft Sans Serif
false
199
145
138
18
None
false
6
false
11959
16
InputField
misc
10
Microsoft Sans Serif
false
567
125
190
18
None
false
5
false
11958
16
InputField
misc
10
Microsoft Sans Serif
false
230
125
265
18
None
false
4
false
11957
16
InputField
Birthdate
10
Microsoft Sans Serif
false
612
105
145
18
None
false
3
false
11956
16
InputField
FName
10
Microsoft Sans Serif
false
387
105
155
18
None
false
2
false
11954
16
StaticText
Date: [dateToday]
10
Microsoft Sans Serif
false
105
1081
120
18
None
false
0
false
11955
16
InputField
LName
10
Microsoft Sans Serif
false
151
105
155
18
None
false
1
false
11952
16
SigBox
0
false
261
1080
364
81
None
true
0
false
11953
16
StaticText
<-- Click here then sign on the signature pad
10
Microsoft Sans Serif
false
630
1080
145
55
None
false
0
false
11949
16
Line
0
false
385
1041
155
0
None
false
0
false
11950
16
StaticText
Who referred you to us? Or how did you hear about us?
10
Microsoft Sans Serif
false
75
1044
350
18
None
false
0
false
11951
16
Line
0
false
427
1062
302
0
None
false
0
false
11947
16
StaticText
New patients:
10
Microsoft Sans Serif
false
75
1004
87
18
None
false
0
false
11948
16
StaticText
Do you have x-rays available for your visit today?
10
Microsoft Sans Serif
false
75
1023
310
18
None
false
0
false
11945
16
Line
0
false
220
1002
275
0
None
false
0
false
11946
16
Line
0
false
603
1002
154
0
None
false
0
false
11944
16
StaticText
Are you in pain?
10
Microsoft Sans Serif
false
500
984
103
18
None
false
0
false
11942
16
Line
0
false
307
982
450
0
None
false
0
false
11943
16
StaticText
Reason for today's visit
10
Microsoft Sans Serif
false
75
984
165
18
None
false
0
false
11933
16
Rectangle
0
false
412
912
14
14
None
false
0
false
11934
16
Rectangle
0
false
433
912
14
14
None
false
0
false
11935
16
Rectangle
0
false
76
913
14
14
None
false
0
false
11936
16
Rectangle
0
false
97
913
14
14
None
false
0
false
11937
16
StaticText
How tall are you?
10
Microsoft Sans Serif
false
75
939
115
18
None
false
0
false
11938
16
StaticText
How much do you weigh?
10
Microsoft Sans Serif
false
306
939
163
18
None
false
0
false
11939
16
Line
0
false
192
957
100
0
None
false
0
false
11940
16
Line
0
false
471
957
100
0
None
false
0
false
11941
16
StaticText
Unusual reaction to dental injections?
10
Microsoft Sans Serif
false
75
964
232
18
None
false
0
false
11927
16
Rectangle
0
false
412
891
14
14
None
false
0
false
11928
16
Rectangle
0
false
433
891
14
14
None
false
0
false
11929
16
Rectangle
0
false
75
892
14
14
None
false
0
false
11930
16
Rectangle
0
false
96
892
14
14
None
false
0
false
11931
16
StaticText
Other Health Problems
10
Microsoft Sans Serif
false
460
909
280
18
None
false
0
false
11932
16
StaticText
Pregnant Now / Could Possibly be Pregant
10
Microsoft Sans Serif
false
123
910
280
18
None
false
0
false
11926
16
StaticText
Radiation treatment
10
Microsoft Sans Serif
false
122
889
280
18
None
false
0
false
11925
16
StaticText
Psychiatric Treatment
10
Microsoft Sans Serif
false
459
888
280
18
None
false
0
false
11924
16
Rectangle
0
false
96
870
14
14
None
false
0
false
11922
16
Rectangle
0
false
433
869
14
14
None
false
0
false
11923
16
Rectangle
0
false
75
870
14
14
None
false
0
false
11921
16
Rectangle
0
false
412
869
14
14
None
false
0
false
11920
16
StaticText
Pacemaker or Defibrillator
10
Microsoft Sans Serif
false
123
867
280
18
None
false
0
false
11919
16
StaticText
Back Problems
10
Microsoft Sans Serif
false
459
866
280
18
None
false
0
false
11918
16
Rectangle
0
false
96
848
14
14
None
false
0
false
11915
16
Rectangle
0
false
412
847
14
14
None
false
0
false
11916
16
Rectangle
0
false
433
847
14
14
None
false
0
false
11917
16
Rectangle
0
false
75
848
14
14
None
false
0
false
11914
16
StaticText
Smoke Other Drugs
10
Microsoft Sans Serif
false
122
845
280
18
None
false
0
false
11912
16
Rectangle
0
false
96
826
14
14
None
false
0
false
11913
16
StaticText
Arthritis
10
Microsoft Sans Serif
false
459
844
280
18
None
false
0
false
11910
16
Rectangle
0
false
433
825
14
14
None
false
0
false
11911
16
Rectangle
0
false
75
826
14
14
None
false
0
false
11909
16
Rectangle
0
false
412
825
14
14
None
false
0
false
11908
16
StaticText
Smoke Tobacco
10
Microsoft Sans Serif
false
123
823
280
18
None
false
0
false
11907
16
StaticText
Skin Disease
10
Microsoft Sans Serif
false
459
822
280
18
None
false
0
false
11906
16
Rectangle
0
false
96
804
14
14
None
false
0
false
11905
16
Rectangle
0
false
75
804
14
14
None
false
0
false
11903
16
Rectangle
0
false
412
803
14
14
None
false
0
false
11904
16
Rectangle
0
false
433
803
14
14
None
false
0
false
11902
16
StaticText
COPD or other Lung Disease
10
Microsoft Sans Serif
false
122
801
280
18
None
false
0
false
11899
16
Rectangle
0
false
75
782
14
14
None
false
0
false
11900
16
Rectangle
0
false
96
782
14
14
None
false
0
false
11901
16
StaticText
Thyroid Disease
10
Microsoft Sans Serif
false
459
800
280
18
None
false
0
false
11897
16
Rectangle
0
false
412
781
14
14
None
false
0
false
11898
16
Rectangle
0
false
433
781
14
14
None
false
0
false
11896
16
StaticText
Irregular heartbeat or palpitations
10
Microsoft Sans Serif
false
122
779
280
18
None
false
0
false
11895
16
StaticText
Family or personal problem with anesthesia
10
Microsoft Sans Serif
false
459
776
280
18
None
false
0
false
11892
16
Rectangle
0
false
433
758
14
14
None
false
0
false
11893
16
Rectangle
0
false
75
760
14
14
None
false
0
false
11894
16
Rectangle
0
false
96
760
14
14
None
false
0
false
11891
16
Rectangle
0
false
412
758
14
14
None
false
0
false
11890
16
StaticText
Artificial Heart Valves
10
Microsoft Sans Serif
false
122
757
280
18
None
false
0
false
11886
16
Rectangle
0
false
96
737
14
14
None
false
0
false
11887
16
Rectangle
0
false
412
737
14
14
None
false
0
false
11888
16
Rectangle
0
false
433
737
14
14
None
false
0
false
11889
16
StaticText
Sleep Apnea or gasp for air when sleeping
10
Microsoft Sans Serif
false
460
755
280
18
None
false
0
false
11884
16
StaticText
Rheumatic Heart Disease
10
Microsoft Sans Serif
false
460
734
280
18
None
false
0
false
11885
16
Rectangle
0
false
75
737
14
14
None
false
0
false
11883
16
StaticText
Heart Failure
10
Microsoft Sans Serif
false
122
734
280
18
None
false
0
false
11882
16
Rectangle
0
false
433
715
14
14
None
false
0
false
11881
16
Rectangle
0
false
412
715
14
14
None
false
0
false
11879
16
Rectangle
0
false
75
715
14
14
None
false
0
false
11880
16
Rectangle
0
false
96
715
14
14
None
false
0
false
11874
16
Rectangle
0
false
96
693
14
14
None
false
0
false
11875
16
Rectangle
0
false
412
693
14
14
None
false
0
false
11876
16
Rectangle
0
false
433
693
14
14
None
false
0
false
11877
16
StaticText
High Blood Pressure
10
Microsoft Sans Serif
false
122
712
280
18
None
false
0
false
11878
16
StaticText
Ulcers
10
Microsoft Sans Serif
false
459
712
280
18
None
false
0
false
11873
16
Rectangle
0
false
75
693
14
14
None
false
0
false
11872
16
StaticText
Stroke
10
Microsoft Sans Serif
false
459
690
280
18
None
false
0
false
11871
16
StaticText
Heart Attack
10
Microsoft Sans Serif
false
122
690
280
18
None
false
0
false
11868
16
Rectangle
0
false
96
671
14
14
None
false
0
false
11869
16
Rectangle
0
false
412
671
14
14
None
false
0
false
11870
16
Rectangle
0
false
433
671
14
14
None
false
0
false
11867
16
Rectangle
0
false
75
671
14
14
None
false
0
false
11866
16
StaticText
Sinus Trouble
10
Microsoft Sans Serif
false
459
668
280
18
None
false
0
false
11865
16
StaticText
Heart Murmur
10
Microsoft Sans Serif
false
122
668
280
18
None
false
0
false
11862
16
Rectangle
0
false
433
648
14
14
None
false
0
false
11863
16
Rectangle
0
false
75
649
14
14
None
false
0
false
11864
16
Rectangle
0
false
96
649
14
14
None
false
0
false
11861
16
Rectangle
0
false
412
648
14
14
None
false
0
false
11860
16
StaticText
Diabetes
10
Microsoft Sans Serif
false
122
646
280
18
None
false
0
false
11859
16
StaticText
Hepatitis
10
Microsoft Sans Serif
false
459
645
280
18
None
false
0
false
11856
16
Rectangle
0
false
96
627
14
14
None
false
0
false
11857
16
Rectangle
0
false
412
627
14
14
None
false
0
false
11858
16
Rectangle
0
false
433
627
14
14
None
false
0
false
11853
16
StaticText
Cancer
10
Microsoft Sans Serif
false
122
624
280
18
None
false
0
false
11855
16
Rectangle
0
false
75
627
14
14
None
false
0
false
11854
16
StaticText
Liver Disease
10
Microsoft Sans Serif
false
459
624
280
18
None
false
0
false
11852
16
Rectangle
0
false
433
605
14
14
None
false
0
false
11851
16
Rectangle
0
false
412
605
14
14
None
false
0
false
11850
16
Rectangle
0
false
96
605
14
14
None
false
0
false
11849
16
Rectangle
0
false
75
605
14
14
None
false
0
false
11848
16
StaticText
Kidney Failure or Dialysis
10
Microsoft Sans Serif
false
459
602
280
18
None
false
0
false
11846
16
Rectangle
0
false
433
583
14
14
None
false
0
false
11847
16
StaticText
Bleeding Problems
10
Microsoft Sans Serif
false
122
602
280
18
None
false
0
false
11844
16
Rectangle
0
false
96
583
14
14
None
false
0
false
11845
16
Rectangle
0
false
412
583
14
14
None
false
0
false
11843
16
Rectangle
0
false
75
583
14
14
None
false
0
false
11842
16
StaticText
Kidney Disease
10
Microsoft Sans Serif
false
459
580
280
18
None
false
0
false
11840
16
StaticText
N
10
Microsoft Sans Serif
false
433
562
16
14
None
false
0
false
11841
16
StaticText
Asthma
10
Microsoft Sans Serif
false
122
580
280
18
None
false
0
false
11839
16
StaticText
Y
10
Microsoft Sans Serif
false
412
562
16
14
None
false
0
false
11838
16
StaticText
N
10
Microsoft Sans Serif
false
96
562
16
14
None
false
0
false
11836
16
StaticText
Do you have any of the following medical conditions?
10
Microsoft Sans Serif
false
75
541
400
18
None
false
0
false
11837
16
StaticText
Y
10
Microsoft Sans Serif
false
75
562
16
14
None
false
0
false
11835
16
Line
0
false
75
532
327
0
None
false
0
false
11834
16
StaticText
15
12
Microsoft Sans Serif
false
48
512
25
20
None
false
0
false
11833
16
Line
0
false
75
510
327
0
None
false
0
false
11831
16
Rectangle
0
false
415
496
14
14
None
false
0
false
11832
16
Rectangle
0
false
436
496
14
14
None
false
0
false
11829
16
StaticText
14
12
Microsoft Sans Serif
false
48
489
25
20
None
false
0
false
11830
16
StaticText
Other Food or Environmental Allergies
10
Microsoft Sans Serif
false
461
493
280
18
None
false
0
false
11828
16
Line
0
false
75
488
327
0
None
false
0
false
11826
16
Rectangle
0
false
414
473
14
14
None
false
0
false
11827
16
Rectangle
0
false
435
473
14
14
None
false
0
false
11822
16
Rectangle
0
false
435
451
14
14
None
false
0
false
11823
16
Line
0
false
75
466
327
0
None
false
0
false
11824
16
StaticText
13
12
Microsoft Sans Serif
false
48
468
25
20
None
false
0
false
11825
16
StaticText
Other Drug Allergies
10
Microsoft Sans Serif
false
461
470
280
18
None
false
0
false
11821
16
Rectangle
0
false
414
451
14
14
None
false
0
false
11820
16
StaticText
Keflex or other Cephalosporins
10
Microsoft Sans Serif
false
461
448
280
18
None
false
0
false
11819
16
StaticText
12
12
Microsoft Sans Serif
false
48
447
25
20
None
false
0
false
11818
16
Line
0
false
75
444
327
0
None
false
0
false
11817
16
Rectangle
0
false
435
429
14
14
None
false
0
false
11815
16
StaticText
Morphine
10
Microsoft Sans Serif
false
461
426
280
18
None
false
0
false
11816
16
Rectangle
0
false
414
429
14
14
None
false
0
false
11813
16
Line
0
false
75
420
327
0
None
false
0
false
11814
16
StaticText
11
12
Microsoft Sans Serif
false
48
424
25
20
None
false
0
false
11812
16
Rectangle
0
false
435
407
14
14
None
false
0
false
11809
16
StaticText
10
12
Microsoft Sans Serif
false
48
400
25
20
None
false
0
false
11810
16
StaticText
Sulfa
10
Microsoft Sans Serif
false
461
404
280
18
None
false
0
false
11811
16
Rectangle
0
false
414
407
14
14
None
false
0
false
11808
16
Line
0
false
75
398
327
0
None
false
0
false
11806
16
Rectangle
0
false
414
385
14
14
None
false
0
false
11807
16
Rectangle
0
false
435
385
14
14
None
false
0
false
11802
16
Rectangle
0
false
435
363
14
14
None
false
0
false
11803
16
Line
0
false
75
376
327
0
None
false
0
false
11804
16
StaticText
9
12
Microsoft Sans Serif
false
48
378
25
20
None
false
0
false
11805
16
StaticText
Penicillin or Amoxicillin
10
Microsoft Sans Serif
false
461
382
280
18
None
false
0
false
11798
16
Line
0
false
75
354
327
0
None
false
0
false
11799
16
StaticText
8
12
Microsoft Sans Serif
false
48
357
25
20
None
false
0
false
11800
16
StaticText
Latex
10
Microsoft Sans Serif
false
461
360
280
18
None
false
0
false
11801
16
Rectangle
0
false
414
363
14
14
None
false
0
false
11796
16
Rectangle
0
false
414
341
14
14
None
false
0
false
11797
16
Rectangle
0
false
435
341
14
14
None
false
0
false
11795
16
StaticText
Iodine
10
Microsoft Sans Serif
false
461
338
280
18
None
false
0
false
11794
16
StaticText
7
12
Microsoft Sans Serif
false
48
336
25
20
None
false
0
false
11793
16
Line
0
false
75
332
327
0
None
false
0
false
11792
16
Rectangle
0
false
435
318
14
14
None
false
0
false
11791
16
Rectangle
0
false
414
318
14
14
None
false
0
false
11790
16
StaticText
Ibuprofen, naproxen or NSAIDS
10
Microsoft Sans Serif
false
461
315
280
18
None
false
0
false
11783
16
Line
0
false
75
288
327
0
None
false
0
false
11784
16
StaticText
5
12
Microsoft Sans Serif
false
48
291
25
20
None
false
0
false
11789
16
StaticText
6
12
Microsoft Sans Serif
false
48
314
25
20
None
false
0
false
11788
16
Line
0
false
75
310
327
0
None
false
0
false
11786
16
Rectangle
0
false
414
296
14
14
None
false
0
false
11787
16
Rectangle
0
false
435
296
14
14
None
false
0
false
11785
16
StaticText
Codeine
10
Microsoft Sans Serif
false
461
293
280
18
None
false
0
false
11782
16
Rectangle
0
false
435
274
14
14
None
false
0
false
11780
16
StaticText
Aspirin
10
Microsoft Sans Serif
false
461
271
280
18
None
false
0
false
11781
16
Rectangle
0
false
414
274
14
14
None
false
0
false
11777
16
Rectangle
0
false
435
252
14
14
None
false
0
false
11778
16
Line
0
false
75
266
327
0
None
false
0
false
11779
16
StaticText
4
12
Microsoft Sans Serif
false
48
269
25
20
None
false
0
false
11776
16
Rectangle
0
false
414
252
14
14
None
false
0
false
11775
16
StaticText
Local Anesthetics
10
Microsoft Sans Serif
false
461
249
280
18
None
false
0
false
11772
16
StaticText
N
10
Microsoft Sans Serif
false
435
231
16
14
None
false
0
false
11773
16
Line
0
false
75
244
327
0
None
false
0
false
11774
16
StaticText
3
12
Microsoft Sans Serif
false
48
247
25
20
None
false
0
false
11769
16
Line
0
false
75
222
327
0
None
false
0
false
11770
16
StaticText
2
12
Microsoft Sans Serif
false
48
225
25
20
None
false
0
false
11771
16
StaticText
Y
10
Microsoft Sans Serif
false
414
231
16
14
None
false
0
false
11768
16
StaticText
Please mark whether or not you have the following allergies.
10
Microsoft Sans Serif
false
410
206
375
18
None
false
0
false
11763
16
Rectangle
0
false
601
181
14
14
None
false
0
false
11764
16
StaticText
Yes
10
Microsoft Sans Serif
false
617
181
30
14
None
false
0
false
11765
16
Rectangle
0
false
653
181
14
14
None
false
0
false
11766
16
StaticText
No
10
Microsoft Sans Serif
false
669
181
30
14
None
false
0
false
11767
16
StaticText
1
12
Microsoft Sans Serif
false
49
203
25
20
None
false
0
false
11762
16
StaticText
Are you allergic to anything?
10
Microsoft Sans Serif
false
417
179
180
18
None
false
0
false
11761
16
StaticText
List all medications that you take:
If you take no medications type "None"
10
Microsoft Sans Serif
false
75
171
327
30
None
false
0
false
11760
16
Line
0
false
570
163
187
0
None
false
0
false
11758
16
Line
0
false
199
163
138
0
None
false
0
false
11759
16
Line
0
false
386
163
99
0
None
false
0
false
11757
16
StaticText
Relationship
10
Microsoft Sans Serif
false
490
145
80
18
None
false
0
false
11756
16
StaticText
Phone
10
Microsoft Sans Serif
false
342
145
44
18
None
false
0
false
11754
16
Line
0
false
567
143
190
0
None
false
0
false
11755
16
StaticText
Emergency Contact
10
Microsoft Sans Serif
false
75
145
124
18
None
false
0
false
11753
16
Line
0
false
230
143
265
0
None
false
0
false
11752
16
StaticText
City/State:
10
Microsoft Sans Serif
false
500
125
67
18
None
false
0
false
11747
16
StaticText
Medical History for New Patient
12
Microsoft Sans Serif
true
312
60
275
20
None
false
0
false
11748
16
StaticText
Last Name:
10
Microsoft Sans Serif
false
76
105
75
18
None
false
0
false
11749
16
StaticText
First Name:
10
Microsoft Sans Serif
false
311
105
76
18
None
false
0
false
11750
16
StaticText
Birthdate:
10
Microsoft Sans Serif
false
547
105
65
18
None
false
0
false
11751
16
StaticText
Name of Medical Doctor:
10
Microsoft Sans Serif
false
75
125
155
18
None
false
0