Health History (Spanish)

Stoppelbein & Hardison, DDS

Please correct the errors described below.
Date
Patient's Name
Date of Birth
Spouse Name
Name of Responsible Party
Home Address
City
State
ZIP Code
Home Telephone Number
Work Telephone Number
Patient's Social Security Number
Spouse's Social Security Number
Name of your Dental Insurance company
Group Number:
Policy Number:
Medical Doctor
Other Problems:
Are you under doctor's care now, why?
If you are taking any medicine, list it here:
When did you last see a dentist, who?

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