false
13
Medical History New Patient
MedicalHistory
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Microsoft Sans Serif
850
1100
false
1
false
false
950
13
Line
0
false
430
266
327
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None
false
0
Left
false
-16777216
false
951
13
InputField
inputMed2
10
Microsoft Sans Serif
false
75
226
327
18
None
false
0
Left
false
-16777216
false
952
13
Line
0
false
430
222
327
0
None
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0
Left
false
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false
953
13
InputField
inputMed6
10
Microsoft Sans Serif
false
430
204
327
18
None
false
0
Left
false
-16777216
false
954
13
Line
0
false
430
244
327
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None
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Left
false
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false
955
13
InputField
inputMed7
10
Microsoft Sans Serif
false
430
226
327
18
None
false
0
Left
false
-16777216
false
956
13
Line
0
false
75
244
327
0
None
false
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Left
false
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false
957
13
InputField
inputMed9
10
Microsoft Sans Serif
false
430
270
327
18
None
false
0
Left
false
-16777216
false
958
13
StaticText
Y
10
Microsoft Sans Serif
false
412
346
16
14
None
false
0
Left
false
-16777216
false
959
13
StaticText
N
10
Microsoft Sans Serif
false
96
346
16
14
None
false
0
Left
false
-16777216
false
960
13
StaticText
Y
10
Microsoft Sans Serif
false
75
346
16
14
None
false
0
Left
false
-16777216
false
961
13
CheckBox
allergy:Anesthetic
0
false
77
369
11
11
None
Y
false
0
Left
false
-16777216
false
962
13
Rectangle
0
false
75
367
14
14
None
false
0
Left
false
-16777216
false
963
13
StaticText
N
10
Microsoft Sans Serif
false
433
346
16
14
None
false
0
Left
false
-16777216
false
964
13
Line
0
false
75
310
327
0
None
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0
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false
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false
965
13
InputField
inputMed5
10
Microsoft Sans Serif
false
75
292
327
18
None
false
0
Left
false
-16777216
false
966
13
Line
0
false
430
288
327
0
None
false
0
Left
false
-16777216
false
967
13
StaticText
Are you allergic to any of the following?
10
Microsoft Sans Serif
false
75
325
400
18
None
false
0
Left
false
-16777216
false
968
13
Line
0
false
430
310
327
0
None
false
0
Left
false
-16777216
false
969
13
InputField
inputMed10
10
Microsoft Sans Serif
false
430
292
327
18
None
false
0
Left
false
-16777216
false
970
13
Line
0
false
230
143
265
0
None
false
0
Left
false
-16777216
false
948
13
Line
0
false
75
288
327
0
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false
0
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false
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false
949
13
InputField
inputMed4
10
Microsoft Sans Serif
false
75
270
327
18
None
false
0
Left
false
-16777216
false
947
13
InputField
inputMed3
10
Microsoft Sans Serif
false
75
248
327
18
None
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0
Left
false
-16777216
false
946
13
Line
0
false
75
266
327
0
None
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false
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13
InputField
inputMed8
10
Microsoft Sans Serif
false
430
248
327
18
None
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0
Left
false
-16777216
false
944
13
CheckBox
problem:Kidney Disease
0
false
435
507
11
11
None
N
false
0
Left
false
-16777216
false
943
13
CheckBox
problem:Rheumatic Fever
0
false
414
661
11
11
None
Y
false
0
Left
false
-16777216
false
942
13
Rectangle
0
false
433
659
14
14
None
false
0
Left
false
-16777216
false
941
13
CheckBox
problem:Rheumatic Fever
0
false
435
661
11
11
None
N
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0
Left
false
-16777216
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940
13
CheckBox
problem:Joint Replacement
0
false
98
661
11
11
None
N
false
0
Left
false
-16777216
false
939
13
StaticText
Joint Replacement
10
Microsoft Sans Serif
false
122
656
280
18
None
false
0
Left
false
-16777216
false
938
13
Rectangle
0
false
412
659
14
14
None
false
0
Left
false
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false
937
13
InputField
misc
10
Microsoft Sans Serif
false
364
692
393
18
None
false
0
Left
false
-16777216
false
935
13
Line
0
false
307
730
450
0
None
false
0
Left
false
-16777216
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936
13
StaticText
Unusual reaction to dental injections?
10
Microsoft Sans Serif
false
75
712
232
18
None
false
0
Left
false
-16777216
false
934
13
StaticText
Rheumatic Fever
10
Microsoft Sans Serif
false
459
656
280
18
None
false
0
Left
false
-16777216
false
933
13
StaticText
Tobacco use? If so, what kind and how much?
10
Microsoft Sans Serif
false
75
692
289
18
None
false
0
Left
false
-16777216
false
931
13
Rectangle
0
false
96
659
14
14
None
false
0
Left
false
-16777216
false
932
13
Line
0
false
364
710
393
0
None
false
0
Left
false
-16777216
false
930
13
CheckBox
problem:High Blood Pressure
0
false
98
639
11
11
None
N
false
0
Left
false
-16777216
false
929
13
StaticText
High Blood Pressure
10
Microsoft Sans Serif
false
122
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280
18
None
false
0
Left
false
-16777216
false
928
13
Rectangle
0
false
412
637
14
14
None
false
0
Left
false
-16777216
false
927
13
Rectangle
0
false
75
637
14
14
None
false
0
Left
false
-16777216
false
926
13
CheckBox
problem:High Blood Pressure
0
false
77
639
11
11
None
Y
false
0
Left
false
-16777216
false
925
13
Rectangle
0
false
96
637
14
14
None
false
0
Left
false
-16777216
false
924
13
StaticText
Ulcers
10
Microsoft Sans Serif
false
459
634
280
18
None
false
0
Left
false
-16777216
false
923
13
Rectangle
0
false
75
659
14
14
None
false
0
Left
false
-16777216
false
922
13
CheckBox
problem:Joint Replacement
0
false
77
661
11
11
None
Y
false
0
Left
false
-16777216
false
921
13
CheckBox
problem:Ulcers
0
false
414
639
11
11
None
Y
false
0
Left
false
-16777216
false
920
13
Rectangle
0
false
433
637
14
14
None
false
0
Left
false
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false
919
13
CheckBox
problem:Ulcers
0
false
435
639
11
11
None
N
false
0
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false
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false
918
13
InputField
misc
10
Microsoft Sans Serif
false
238
812
275
18
None
false
0
Left
false
-16777216
false
916
13
Line
0
false
582
830
175
0
None
false
0
Left
false
-16777216
false
917
13
StaticText
City/State
10
Microsoft Sans Serif
false
518
812
64
18
None
false
0
Left
false
-16777216
false
915
13
InputField
misc
10
Microsoft Sans Serif
false
455
792
302
18
None
false
0
Left
false
-16777216
false
913
13
Line
0
false
238
830
275
0
None
false
0
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false
-16777216
false
914
13
StaticText
Name of former dentist
10
Microsoft Sans Serif
false
95
812
143
18
None
false
0
Left
false
-16777216
false
912
13
InputField
misc
10
Microsoft Sans Serif
false
287
832
470
18
None
false
0
Left
false
-16777216
false
911
13
StaticText
Date: [dateToday]
10
Microsoft Sans Serif
false
75
872
120
18
None
false
0
Left
false
-16777216
false
910
13
SigBox
0
false
261
912
364
81
None
false
0
Left
false
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false
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13
InputField
misc
10
Microsoft Sans Serif
false
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None
false
0
Left
false
-16777216
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908
13
StaticText
Date of last cleaning and exam
10
Microsoft Sans Serif
false
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832
192
18
None
false
0
Left
false
-16777216
false
906
13
Line
0
false
455
810
302
0
None
false
0
Left
false
-16777216
false
907
13
Line
0
false
287
850
470
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false
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13
InputField
misc
10
Microsoft Sans Serif
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None
false
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false
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false
903
13
Line
0
false
603
750
154
0
None
false
0
Left
false
-16777216
false
904
13
StaticText
Are you in pain?
10
Microsoft Sans Serif
false
500
732
103
18
None
false
0
Left
false
-16777216
false
902
13
InputField
misc
10
Microsoft Sans Serif
false
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None
false
0
Left
false
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false
901
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StaticText
Reason for today's visit
10
Microsoft Sans Serif
false
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732
145
18
None
false
0
Left
false
-16777216
false
899
13
Line
0
false
602
790
155
0
None
false
0
Left
false
-16777216
false
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13
Line
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false
220
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275
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13
InputField
misc
10
Microsoft Sans Serif
false
602
772
155
18
None
false
0
Left
false
-16777216
false
897
13
StaticText
Do you have BiteWing x-rays that are less than 1 year old?
10
Microsoft Sans Serif
false
95
792
360
18
None
false
0
Left
false
-16777216
false
896
13
InputField
misc
10
Microsoft Sans Serif
false
603
732
154
18
None
false
0
Left
false
-16777216
false
895
13
StaticText
New patients:
10
Microsoft Sans Serif
false
75
752
87
18
None
false
0
Left
false
-16777216
false
894
13
StaticText
Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?
10
Microsoft Sans Serif
false
95
772
507
18
None
false
0
Left
false
-16777216
false
893
13
StaticText
Stroke
10
Microsoft Sans Serif
false
459
612
280
18
None
false
0
Left
false
-16777216
false
892
13
Rectangle
0
false
412
549
14
14
None
false
0
Left
false
-16777216
false
891
13
CheckBox
problem:Pregnancy
0
false
414
551
11
11
None
Y
false
0
Left
false
-16777216
false
890
13
Rectangle
0
false
433
549
14
14
None
false
0
Left
false
-16777216
false
889
13
Rectangle
0
false
96
549
14
14
None
false
0
Left
false
-16777216
false
888
13
CheckBox
problem:Cancer
0
false
98
551
11
11
None
N
false
0
Left
false
-16777216
false
887
13
StaticText
Cancer
10
Microsoft Sans Serif
false
122
546
280
18
None
false
0
Left
false
-16777216
false
886
13
CheckBox
problem:Diabetes
0
false
77
573
11
11
None
Y
false
0
Left
false
-16777216
false
885
13
Rectangle
0
false
96
571
14
14
None
false
0
Left
false
-16777216
false
884
13
CheckBox
problem:Diabetes
0
false
98
573
11
11
None
N
false
0
Left
false
-16777216
false
883
13
CheckBox
problem:Pregnancy
0
false
435
551
11
11
None
N
false
0
Left
false
-16777216
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882
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StaticText
Pregnancy
10
Microsoft Sans Serif
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459
546
280
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None
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0
Left
false
-16777216
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881
13
Rectangle
0
false
75
571
14
14
None
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0
Left
false
-16777216
false
880
13
CheckBox
problem:Cancer
0
false
77
551
11
11
None
Y
false
0
Left
false
-16777216
false
879
13
Rectangle
0
false
96
527
14
14
None
false
0
Left
false
-16777216
false
878
13
CheckBox
problem:Bleeding Problems
0
false
98
529
11
11
None
N
false
0
Left
false
-16777216
false
877
13
StaticText
Bleeding Problems
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Microsoft Sans Serif
false
122
524
280
18
None
false
0
Left
false
-16777216
false
876
13
StaticText
Kidney Disease
10
Microsoft Sans Serif
false
459
502
280
18
None
false
0
Left
false
-16777216
false
875
13
Rectangle
0
false
75
527
14
14
None
false
0
Left
false
-16777216
false
874
13
CheckBox
problem:Bleeding Problems
0
false
77
529
11
11
None
Y
false
0
Left
false
-16777216
false
873
13
CheckBox
problem:Liver Disease
0
false
435
529
11
11
None
N
false
0
Left
false
-16777216
false
872
13
StaticText
Liver Disease
10
Microsoft Sans Serif
false
459
524
280
18
None
false
0
Left
false
-16777216
false
871
13
Rectangle
0
false
75
549
14
14
None
false
0
Left
false
-16777216
false
869
13
CheckBox
problem:Liver Disease
0
false
414
529
11
11
None
Y
false
0
Left
false
-16777216
false
870
13
Rectangle
0
false
412
527
14
14
None
false
0
Left
false
-16777216
false
868
13
Rectangle
0
false
433
527
14
14
None
false
0
Left
false
-16777216
false
867
13
Rectangle
0
false
75
615
14
14
None
false
0
Left
false
-16777216
false
866
13
CheckBox
problem:Heart Trouble
0
false
77
617
11
11
None
Y
false
0
Left
false
-16777216
false
865
13
Rectangle
0
false
96
615
14
14
None
false
0
Left
false
-16777216
false
864
13
Rectangle
0
false
433
593
14
14
None
false
0
Left
false
-16777216
false
863
13
CheckBox
problem:Sinus Trouble
0
false
435
595
11
11
None
N
false
0
Left
false
-16777216
false
862
13
StaticText
Sinus Trouble
10
Microsoft Sans Serif
false
459
590
280
18
None
false
0
Left
false
-16777216
false
861
13
CheckBox
problem:Stroke
0
false
414
617
11
11
None
Y
false
0
Left
false
-16777216
false
860
13
Rectangle
0
false
433
615
14
14
None
false
0
Left
false
-16777216
false
859
13
CheckBox
problem:Stroke
0
false
435
617
11
11
None
N
false
0
Left
false
-16777216
false
858
13
CheckBox
problem:Heart Trouble
0
false
98
617
11
11
None
N
false
0
Left
false
-16777216
false
857
13
StaticText
Heart Trouble
10
Microsoft Sans Serif
false
122
612
280
18
None
false
0
Left
false
-16777216
false
856
13
Rectangle
0
false
412
615
14
14
None
false
0
Left
false
-16777216
false
855
13
CheckBox
problem:Sinus Trouble
0
false
414
595
11
11
None
Y
false
0
Left
false
-16777216
false
854
13
Rectangle
0
false
433
571
14
14
None
false
0
Left
false
-16777216
false
853
13
CheckBox
problem:Psychiatric Treatment
0
false
435
573
11
11
None
N
false
0
Left
false
-16777216
false
852
13
StaticText
Psychiatric Treatment
10
Microsoft Sans Serif
false
459
568
280
18
None
false
0
Left
false
-16777216
false
851
13
StaticText
Diabetes
10
Microsoft Sans Serif
false
122
568
280
18
None
false
0
Left
false
-16777216
false
850
13
Rectangle
0
false
412
571
14
14
None
false
0
Left
false
-16777216
false
849
13
CheckBox
problem:Psychiatric Treatment
0
false
414
573
11
11
None
Y
false
0
Left
false
-16777216
false
848
13
CheckBox
problem:Heart Murmur
0
false
98
595
11
11
None
N
false
0
Left
false
-16777216
false
847
13
StaticText
Heart Murmur
10
Microsoft Sans Serif
false
122
590
280
18
None
false
0
Left
false
-16777216
false
846
13
Rectangle
0
false
412
593
14
14
None
false
0
Left
false
-16777216
false
845
13
Rectangle
0
false
75
593
14
14
None
false
0
Left
false
-16777216
false
844
13
CheckBox
problem:Heart Murmur
0
false
77
595
11
11
None
Y
false
0
Left
false
-16777216
false
843
13
Rectangle
0
false
96
593
14
14
None
false
0
Left
false
-16777216
false
978
13
StaticText
Medical History for New Patient
12
Microsoft Sans Serif
true
312
60
275
20
None
false
0
Left
false
-16777216
false
977
13
StaticText
Last Name:
10
Microsoft Sans Serif
false
76
105
75
18
None
false
0
Left
false
-16777216
false
976
13
InputField
LName
10
Microsoft Sans Serif
false
151
105
155
18
None
false
0
Left
false
-16777216
false
975
13
InputField
misc
10
Microsoft Sans Serif
false
230
125
265
18
None
false
0
Left
false
-16777216
false
974
13
StaticText
City/State:
10
Microsoft Sans Serif
false
500
125
67
18
None
false
0
Left
false
-16777216
false
973
13
Line
0
false
567
143
190
0
None
false
0
Left
false
-16777216
false
972
13
InputField
Birthdate
10
Microsoft Sans Serif
false
612
105
145
18
None
false
0
Left
false
-16777216
false
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List all medications that you are now taking:
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