Health History Form

Please correct the errors described below.

An accurate and complete health history will assist in coordinating your dental care. Please speak with the doctor or staff if there are any questions about this form.

Dental History

DENTAL HISTORY - Do you have or have you ever had any of the following:

Medical History

Do you have, or have you ever had, any of the following conditions

FAMILY MEDICAL HISTORY - Do you have a family history of any of the following conditions?

MEDICATIONS – Are you currently prescribed or taking any of the following:

Please list the specific medications indicated above and/or any other medications not listed above that you are currently taking. Please including all prescription medications, diet drugs, over the counter medications, herbal or holistic remedies, vitamins, or minerals:.

Add Medication and Dose

ALLERGIES – Are you allergic to or have you had an adverse reaction to:

ANESTHESIA HISTORY

FEMALE PATIENTS

SOCIAL HISTORY

Have you ever sought professional care or been hospitalized for:

Do you use:

I understand the importance of a truthful and complete health history to assist my doctor in providing coordinated care. To the best of my knowledge, the above information is complete and correct.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

For office staff use - HEALTH HISTORY REVIEW

Add Health History Review

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