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MICHAEL L. SHAPIRO D.M.D., P.C.838 Pleasant Street Brockton, MA 02301 (508) 586-6002 Medical/Dental HistoryPatient Name: Last First MI Preferred NameYour current physical health is: good fair poor Are you currently under the care of a physician? If yes, please explain. Please select/verify if you have or had any of the following medical conditions:Abnormal Bleeding Allergy-ErthoAllergy-N-SaidsAllergy-TetracyclineArtificial bone/PinBlood Pressure-HighChemo TxDry MouthHandicap AccessHeart MurmurHepatitisLiver ProblemsPsychiatric CareRheumatismSinus ProblemsTBAllergy-AnestheticsAllergy-Hay FeverAllergy-OtherAnemiaArtificial JointBlood Pressure-LowCongen Heart DefectEmphysemaHeadache/MigraineHeart MVPHIV/AIDS/ARCMeds-See ListRadiation TxSee Med HxSTDsThyroid DiseaseAllergy-AspirinAllergy-LatexAllergy-PenicillinAnxietyAsthmaBlood TransfusionDiabetesEpilepsy/SeizuresHeart AttackHeart SurgeryImmunosupressedPacemakerRespiratory DisorderSensory ImpairmentStomach ProblemsTumorsAllergy-CodeineAllergy-MetalsAllergy-SulfaArthritisBlood DiseaseCancerDrug/Alcohol AbuseGlaucomaHeart DiseaseHeart Valve ReplacedKidney ProblemsPREMEDRheumatic FeverShinglesStrokeUlcersMichael L. Shapiro D.M.D., P.C.838 Pleasant StreetBrockton, MA 02301 (508) 586-6002Please list any additional medical conditions or clarify anything checked off. Enter N/A if applicablePlease list any other allergies here. If none enter NONE. Are you taking any prescription/counter drugs? If yes, please list each one. Have you ever been hospitalized? If yes, please explain. Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax, Atonel, Atelva, Boniva , Reclast, Prolla) for osteoporosis or Paget’s disease? Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia, Zometa, XGEVA) for bone pain, hypercalcemia, or skeletal complications resulting from paget’s disease, multiple myeloma, or metastatic cancer? If yes, date treatment began: FOR WOMEN – Check all that apply Taking birth control pills Currently Pregnant Currently nursing None of the aboveI understand that the information that I have given is correct to the best of my knowledge. I also understand that the information will be held in strictest confidence and it is my responsibility to inform this office of any changes in my medical status. Response Date: ................
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