Medical History Information
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that may have , or medication that you may be taking, could have an important interrelationship with the dentistry you will recieve.
Women: Are you...
Are you allergic to any of the following?
Do you have, or have you had, any of the following?
Comments:
FOR OFFICE STAFF USE ONLY:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerours to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical history.