Patient Health History
First Name
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Last Name
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Today's Date
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Please describe the reason for your visit:
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Have you noticed or has any dentist or hygienist ever said that you:
Health History
Are you in good health?
Yes, I am in good health.
No, I am not in good health.
Please Check if you have any of the following:
Month
Birth control pills
Headaches, ringing in ears
Hip or knee implant
List any and all allergies
List any and all DRUGS/MEDICATIONS you are currently taking
List any and all SURGERIES
List any ill effects from Novocain, Penicillin or any other drug
Yes, I have experience an unfavorable reaction from previous dental treatment
Are you being treated by a Physician now? Who?
Patient / Guardian Signature
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Submit
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