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Home
Our Practice
Meet Our Dentists
Meet Our Team
Office Tour
Dental Services
Cosmetic Dentistry
Ceramic Dental Inlays and Onlays
Cosmetic Dental Bonding
Dental Veneers
Teeth Whitening
Dental Fillings Syracuse
Dental Implants & Abutments
Emergency Dental Care
General & Family Dentistry
Teeth Cleaning Syracuse
Periodontics Syracuse
Endodontics Syracuse
Wisdom Teeth Removal
Orthodontics
ClearCorrect
Orthodontic Before & After Gallery
VIP’s Newest Dental Technologies
Air Abrasion – Microdentistry
CariVu Cavity Detection
CEREC One-Visit Dental Crowns
DIAGNOdent Laser Cavity Detection
Digital Dental X-Rays
Laser Dentistry
Snoring & Sleep Apnea Treatments
For Patients
Financial Options
Patient Forms
Gallery
Live Longer & Healthier
Special Offers
Teeth Whitening Special
Complimentary Orthodontic Consultation
Complimentary Second Opinion or Emergency Exam
Complimentary Dental Implant Consultation
Whitening
VIP Savings Plan
Reviews
Blog
Contact
New Patient Form – Test
New Patient Form
Please fill out all the information to the best of your knowledge.
All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you.
Date: Month
01
02
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Day
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31
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
Patient #
Title
Mr.
Ms.
Mrs.
Dr.
First Name
*
Middle Name
*
Last_Name
*
I prefer to be called:
Sex
M
F
Age
Marital Status:
Minor
Single
Married
Long-Term Partner
Divorced
Widowed
Separated
Date of Birth: Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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1997
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1995
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1993
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1991
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1986
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1983
1982
1981
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1978
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1974
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1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
1899
1898
1897
1896
1895
1894
1893
1892
1891
1890
1889
1888
1887
1886
Social Security #
Drivers License State
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Drivers License #
Home Phone
*
Work Phone
Cell Phone
Email Address
Home Address:
City:
State:
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
ZIP:
Employment Status:
None
Full-Time
Part-Time
Retired
Employer's Name
Employer's Phone:
Occupation:
Employer's Address
City:
State:
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
ZIP:
Student_Status
Not a Student
Full-Time
Part-Time
Student_Status_txt
School_Name
Grade
Best_Contact
Reminder_1
First Choice
Second Choice
Third Choice
Reminder_2
First Choice
Second Choice
Third Choice
Reminder_3
First Choice
Second Choice
Third Choice
How_Found1
First Choice
Second Choice
Third Choice
How_Found1_text
How_Found2
First Choice
Second Choice
Third Choice
How_Found3
First Choice
Second Choice
Third Choice
How_Found4
First Choice
Second Choice
Third Choice
How_Found5
First Choice
Second Choice
Third Choice
How_Found6
First Choice
Second Choice
Third Choice
How_Found7
First Choice
Second Choice
Third Choice
How_Found8
First Choice
Second Choice
Third Choice
How_Found9
First Choice
Second Choice
Third Choice
How_Found10
First Choice
Second Choice
Third Choice
How_Found10_text
How_Found11
First Choice
Second Choice
Third Choice
How_Found11_text
website_factor
website_factor
website_factor
Spouse_Parent_Name
Spouse_Parent_Employer_Name
Spouse_Parent_Work_Phone_1
Spouse_Parent_Work_Phone_2
Spouse_Parent_Work_Phone_3
Spouse_Parent_Cell_Phone_1
Spouse_Parent_Cell_Phone_2
Spouse_Parent_Cell_Phone_3
Additional_Family_Members
Comments
Emergency_Contact_Title
Mr.
Ms.
Mrs.
Dr.
Emergency_Contact_Title_txt
Emergency_Contact_First_Name
Emergency_Contact_Last_Name
Emergency_Contact_Relationship
Emergency_Contact_Phone_Home_1
Emergency_Contact_Phone_Home_2
Emergency_Contact_Phone_Home_3
Emergency_Contact_Phone_Work_1
Emergency_Contact_Phone_Work_2
Emergency_Contact_Phone_Work_3
Emergency_Contact_Phone_Cell_1
Emergency_Contact_Phone_Cell_2
Emergency_Contact_Phone_Cell_3
Emergency_Contact_Email
Emergency_Contact_Address
Emergency_Contact_City
Emergency_Contact_State
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Emergency_Contact_State_txt
Emergency_Contact_ZIP
Responsible_Person_Title
Mr.
Ms.
Mrs.
Dr.
Responsible_Person_Title_txt
Responsible_Person_First_Name
Responsible_Person_Middle_Name
Responsible_Person_Last_Name
Responsible_Person_Relationship
Responsible_Person_DOB_m
01
02
03
04
05
06
07
08
09
10
11
12
Responsible_Person_DOB_m_txt
Responsible_Person_DOB_d
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Responsible_Person_DOB_d_txt
Responsible_Person_DOB_y
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
1899
1898
1897
1896
1895
1894
1893
1892
1891
1890
1889
1888
1887
1886
Responsible_Person_DOB_y_txt
Responsible_Person_SSN_1
Responsible_Person_SSN_2
Responsible_Person_SSN_3
Responsible_Person_DL_State
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Responsible_Person_DL_State_txt
Responsible_Person_DL_Number
Responsible_Person_Insurance
No
Yes: Primary Insurance Policy
Yes: Secondary Insurance Policy
Responsible_Person_Insurance_txt
Responsible_Person_Phone_Home_1
Responsible_Person_Phone_Home_2
Responsible_Person_Phone_Home_3
Responsible_Person_Phone_Work_1
Responsible_Person_Phone_Work_2
Responsible_Person_Phone_Work_3
Responsible_Person_Phone_Cell_1
Responsible_Person_Phone_Cell_2
Responsible_Person_Phone_Cell_3
Responsible_Person_Email
Billing_Address
Billing_City
Billing_State
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Billing_State_txt
Billing_ZIP
Responsible_Person_Employment_Status
None
Full-Time
Part-Time
Retired
Responsible_Person_Employment_Status_txt
Responsible_Person_Employer_Name
Responsible_Person_Phone_Employer_1
Responsible_Person_Phone_Employer_2
Responsible_Person_Phone_Employer_3
Responsible_Person_Occupation
Responsible_Person_Work_Address
Responsible_Person_Work_City
Responsible_Person_Work_State
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Responsible_Person_Work_State_txt
Responsible_Person_Work_ZIP
Primary_Insurance_Name
Primary_Insurance_DOB_m
01
02
03
04
05
06
07
08
09
10
11
12
Primary_Insurance_DOB_m_txt
Primary_Insurance_DOB_d
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Primary_Insurance_DOB_d_txt
Primary_Insurance_DOB_y
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
1899
1898
1897
1896
1895
1894
1893
1892
1891
1890
1889
1888
1887
1886
Primary_Insurance_DOB_y_txt
Primary_Insurance_Relationship
Primary_Insurance_Employer
Primary_Insurance_Member_ID
Primary_Insurance_Group_ID
Primary_Insurance_Company_Name
Primary_Insurance_Phone_1
Primary_Insurance_Phone_2
Primary_Insurance_Phone_3
Primary_Insurance_SSN
Primary_Insurance_Address
Primary_Insurance_City
Primary_Insurance_State
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Primary_Insurance_State_txt
Primary_Insurance_ZIP
Secondary_Insurance_Name
Secondary_Insurance_DOB_m
01
02
03
04
05
06
07
08
09
10
11
12
Secondary_Insurance_DOB_m_txt
Secondary_Insurance_DOB_d
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Secondary_Insurance_DOB_d_txt
Secondary_Insurance_DOB_y
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
1899
1898
1897
1896
1895
1894
1893
1892
1891
1890
1889
1888
1887
1886
Secondary_Insurance_DOB_y_txt
Secondary_Insurance_Relationship
Secondary_Insurance_Employer
Secondary_Insurance_Member_ID
Secondary_Insurance_Group_ID
Secondary_Insurance_Company_Name
Secondary_Insurance_Phone_1
Secondary_Insurance_Phone_2
Secondary_Insurance_Phone_3
Secondary_Insurance_SSN
Secondary_Insurance_Address
Secondary_Insurance_City
Secondary_Insurance_State
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Secondary_Insurance_State_txt
Secondary_Insurance_ZIP
Insurance_Consent_Signature
Insurance_Consent_Signature_m
01
02
03
04
05
06
07
08
09
10
11
12
Insurance_Consent_Signature_m_txt
Insurance_Consent_Signature_d
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Insurance_Consent_Signature_d_txt
Insurance_Consent_Signature_y
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
Insurance_Consent_Signature_y_txt
Patient_Name_Consent
Treatment_Consent_Signature
Treatment_Consent_Signature_m
01
02
03
04
05
06
07
08
09
10
11
12
Treatment_Consent_Signature_m_txt
Treatment_Consent_Signature_d
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Treatment_Consent_Signature_d_txt
Treatment_Consent_Signature_y
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
Treatment_Consent_Signature_y_txt
Patient_Name_Payment
Payment_Policies_Signature
Payment_Policies_Signature_m
01
02
03
04
05
06
07
08
09
10
11
12
Payment_Policies_Signature_m_txt
Payment_Policies_Signature_d
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Payment_Policies_Signature_d_txt
Payment_Policies_Signature_y
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
Payment_Policies_Signature_y_txt
general_health
general_health
general_health
general_health
current_treatment
Yes
No
current_treatment_txt
current_treatment_details
antibiotic_premedication
Yes
No
antibiotic_premedication_txt
antibiotic_premedication_details
physician_Name
physician_Phone_1
physician_Phone_2
physician_Phone_3
physician_Last_Visit_m
01
02
03
04
05
06
07
08
09
10
11
12
physician_Last_Visit_m_txt
physician_Last_Visit_y
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
1899
1898
1897
1896
1895
1894
1893
1892
1891
1890
1889
1888
1887
1886
physician_Last_Visit_y_txt
contact_physician
contact_physician
contact_physician
MH_HaveYouEverHad_Arthritis
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Arteriosclerosis
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Birth_defects
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Cancer
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Emotional_problems
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Head_or_face_injury
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Heart_murmur_trouble
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_History_of_substance_abuse_drug_addiction
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Kidney_problems
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Numbness_of_arms_or_hands
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Swollen_still_painful_joints
First Choice
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Third Choice
MH_HaveYouEverHad_Allergies
First Choice
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Third Choice
MH_HaveYouEverHad_Asthma
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Blood_disease
First Choice
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MH_HaveYouEverHad_Diabetes
First Choice
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Third Choice
MH_HaveYouEverHad_Endocrine_problems
First Choice
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Third Choice
MH_HaveYouEverHad_Intestinal_disorders
First Choice
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Third Choice
MH_HaveYouEverHad_Hepatitis_a_b_or_c
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Hypertension_high_blood_pressure
First Choice
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Third Choice
MH_HaveYouEverHad_Liver_problems
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Pneumonia
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Shortness_of_breath
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Anemia
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Bruise_easily
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Dizziness
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Epilepsy
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Seizures
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Fainting
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Hearing_disorders
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_High_or_low_blood_sugar
First Choice
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Third Choice
MH_HaveYouEverHad_Hypotension_low_blood_pressure
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Nervous_disorder
First Choice
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Third Choice
MH_HaveYouEverHad_Rheumatic_fever
First Choice
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MH_HaveYouEverHad_Heart_attack_stroke
First Choice
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Third Choice
MH_HaveYouEverHad_Heart_surgery
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Pacemaker
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Artificial_valves
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Congenital_heart_defect
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Mitral_valve_prolapse
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Artificial_bones_joints
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Shingles
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_HIV_AIDS
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Blood_transfusions
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Fever_blisters
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Sinus_problems
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Severe_frequent_headaches
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Cancer_chemotherapy
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Radiation_treatments
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Psychiatric_problems
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Tuberculosis
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Venereal_disease
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Hemophilia
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Abnormal_bleeding
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Ulcers_colitis
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Difficulty_breathing
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Hospitalized_for_any_reason
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Emphysema
First Choice
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Third Choice
MH_HaveYouEverHad_Glaucoma
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Thyroid_disease
First Choice
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Third Choice
MH_HaveYouEverHad_Angina
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Artificial_hip_joints
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Gout
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Chest_pain
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Circulatory_problems
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Cold_sores
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Congenital_heart_lesion
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Cortisone_medicine
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Convulsions
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Herpes
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Leukemia
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Excessive_thirst
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Hay_fever
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Heart_disease
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Hives_skin_rash
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Hypoglycemia
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Irregular_heartbeat
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Lung_disease
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Osteoporosis
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Pain_in_jaw_joints
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Parathyroid_disease
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Recent_weight_loss
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Rheumatism
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Scarlet_fever
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Sexually_transmitted_disease
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Sickle_cell_anemia
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Sinus_trouble
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Tattoos_body_piercing
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Tmd_tmj_jaw_pain
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_X-ray_or_cobalt_treatment
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Yellow_jaundice
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Chronic_fatigue_syndrome
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Cough-persistent_or_bloody
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Latex_sensitivity
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Smoker
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Swelling_of_feet_ankles
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Swollen_neck_glands
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Tonsillitis
First Choice
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Third Choice
MH_HaveYouEverHad_Tumor_or_growth_on_head_neck
First Choice
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MH_HaveYouEverHad_Easily_winded
First Choice
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Third Choice
MH_HaveYouEverHad_Anaphylaxis
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Alzheimers_disease
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Frequent_diarrhea
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Genital_herpes
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Renal_dialysis
First Choice
Second Choice
Third Choice
MH_HaveYouEverHad_Spina_bifida
First Choice
Second Choice
Third Choice
MH_reaction_to_Acrylic
First Choice
Second Choice
Third Choice
MH_reaction_to_Aspirin
First Choice
Second Choice
Third Choice
MH_reaction_to_Barbiturates_sleeping_pills
First Choice
Second Choice
Third Choice
MH_reaction_to_Codeine
First Choice
Second Choice
Third Choice
MH_reaction_to_Dental_anesthetics
First Choice
Second Choice
Third Choice
MH_reaction_to_Erythromycin
First Choice
Second Choice
Third Choice
MH_reaction_to_Iodine
First Choice
Second Choice
Third Choice
MH_reaction_to_Latex_rubber
First Choice
Second Choice
Third Choice
MH_reaction_to_Metals
First Choice
Second Choice
Third Choice
MH_reaction_to_Nitrous_oxide
First Choice
Second Choice
Third Choice
MH_reaction_to_Novocain
First Choice
Second Choice
Third Choice
MH_reaction_to_Penicillin/antibiotics
First Choice
Second Choice
Third Choice
MH_reaction_to_Sedatives
First Choice
Second Choice
Third Choice
MH_reaction_to_Sulfa_drugs
First Choice
Second Choice
Third Choice
MH_reaction_to_Tetracycline
First Choice
Second Choice
Third Choice
MH_reaction_to_Valium
First Choice
Second Choice
Third Choice
MH_reaction_to_Xylocaine
First Choice
Second Choice
Third Choice
cancer
Yes
No
cancer_txt
cancer_details
bisphosphonate_drugs
bisphosphonate_drugs
bisphosphonate_drugs
phenfen
phenfen
phenfen
tobacco
tobacco
tobacco
alcohol_drugs
alcohol_drugs
alcohol_drugs
contact_lenses
contact_lenses
contact_lenses
special_diet
special_diet
special_diet
ten_pounds
ten_pounds
ten_pounds
pillows
pillows
pillows
excessive_bleeding
excessive_bleeding
excessive_bleeding
shortness_of_breath
shortness_of_breath
shortness_of_breath
hospital
hospital
hospital
female_pregnant
First Choice
Second Choice
Third Choice
female_pregnant_text
female_trying
First Choice
Second Choice
Third Choice
female_nursing
First Choice
Second Choice
Third Choice
female_birth_control
First Choice
Second Choice
Third Choice
Prescriptions_List
Serious_Conditions
Medical_History_Signature
Medical_History_Signature_m
01
02
03
04
05
06
07
08
09
10
11
12
Medical_History_Signature_m_txt
Medical_History_Signature_d
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Medical_History_Signature_d_txt
Medical_History_Signature_y
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
Medical_History_Signature_y_txt
Reviewed_By
Reviewed_By_Title
Reviewed_m
01
02
03
04
05
06
07
08
09
10
11
12
Reviewed_m_txt
Reviewed_d
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Reviewed_d_txt
Reviewed_y
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
Reviewed_y_txt
HIPAA_Share_Name_1
HIPAA_Share_Relationship_1
HIPAA_Share_Phone_1_1
HIPAA_Share_Phone_2_1
HIPAA_Share_Phone_3_1
HIPAA_Share_Name_2
HIPAA_Share_Relationship_2
HIPAA_Share_Phone_1_2
HIPAA_Share_Phone_2_2
HIPAA_Share_Phone_3_2
HIPAA_Share_Name_3
HIPAA_Share_Relationship_3
HIPAA_Share_Phone_1_3
HIPAA_Share_Phone_2_3
HIPAA_Share_Phone_3_3
HIPAA_Consent_Signature
HIPAA_Consent_Signature_m
01
02
03
04
05
06
07
08
09
10
11
12
HIPAA_Consent_Signature_m_txt
HIPAA_Consent_Signature_d
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
HIPAA_Consent_Signature_d_txt
HIPAA_Consent_Signature_y
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
HIPAA_Consent_Signature_y_txt
HIPAA_Consent_Relationship
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