Thompson Prophy 6-Month 2020

1
Patient Name
First Name
Last Name
2
Patient Date of Birth
Month
Day
Year
3
Relationship to the Patient:i.e. self, parent, guardian, etc
4
Do you have any dental complaints or concerns?
Huge
Large
Normal
Small
Ok
Ok
5
Please list all medications and dosages.Ex: Aspirin - 83 mg, once a day (list each on a separate line)
Huge
Large
Normal
Small
Ok
Ok
6
Has there been a change in your health over the past year?
YESNO
7
Please Explain Your Health Changes.
8
Patient or Guarantor's Signature* This field is required.
Clear
9
Today's Date* This field is required.
Date
Month
Day
Year
Should be Empty: