Health History

So that we may provide you with the best possible care, please complete both the medical and dental history forms. The following information is to be reviewed by the doctor and will be held in the strictest confidence. It is important that you complete the form in its entirety so that we may accurately diagnose and treat you, according to your general health and well-being.

HEALTH HISTORY

Name:
Physician's Name:
Have you been under the care of a medical doctor during the past two years?
If yes, what was the nature or condition of illness? :
Current Medications:
Are you allergic to any of the following:
Other:
Have you been a patient in the hospital in the past five years?
If yes, what was the reason? :
Which of the following do you have or have had?: (Check all that apply)
Do you take Premed for your Artifical Joint?
If so, what kind of premed?
Women:
Do you use more than two pillows to sleep?
Have you ever had any illness not listed above:
If yes, please explain:

Note: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certified that I have read and understand the above and that the information given on this form is accurate. Understand the importance of a truthful health history and that my dentist and her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of her staff, responsible for any action they take or do not take because of errors or omissions that I may have made and the completion of this form. I hereby give my consent to perform necessary diagnostic test (including x-rays) and evaluation of my dental health.

Digital Signature of Patient/Legal Guardian:
Date:
Spam Verification: