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