• HEALTH HISTORY

    Correct answers to the following questions will allow us to treat you on a more individual basis, providing the care appropriate for your particular needs.
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  • Please answer each question below. Check yes or no. 

  • Do you have or have you ever had any of the following? Please indicate yes or no below.

  • GENERAL

  • EYES

  • NOSE

  • NERVOUS SYSTEM

  • HEART/BLOOD VESSELS

  • BONES/MUSCLES

  • DIGESTIVE SYSTEM

  • URINARY

  • BLOOD

  • RESPIRATORY

  • ENDOCRINE

  • OTHER

  • Are you ALLERGIC or have ever experienced any reaction to the following?

  • Are you taking any of the following?

  • To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or change in my medication, I will inform the dentist at the next appointment.

  • Clear
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  • Should be Empty: