Medical History

Although dental personnel primarily treat the area in and around mouth, your mouth is a part of your entire body.

Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive.

Thank you for answering the following questions.

WOMEN

Do you have, or have tou had, any of the following?

If yes, please explain:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can

be dangerous to my (or patient’s) health. It is my responsability to inform the dental office of any changes in medical status.