Patient Health History
Please describe the reason for your visit:
Have you noticed or has any dentist or hygienist ever said that you:
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:
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
Should be Empty: