Confidential Health History
1. Circle Appropriate Answer (Leave blank if you do not understand the question)
2. Have You Ever Experienced Any Of The Following? (Please circle Yes or No for each)
3. Have You Ever Had Or Do You Have Any Of The Following? (Please circle Yes or No for each)
4. Are You Allergic To Or Have You Had A Reaction To Any Of The Following? (Please Circle Yes Or No For Each)
55. Are You Taking Or Have You Taken Any Of The Following In The Last Three Months? (Please Circle Yes Or No For Each)
6. Women Only (Please Circle Yes Or No For Each)
7. All Patients (Please Circle Yes Or No For Each)
If patient answers "yes" to any of the questions above, consider seeking additional information from the patient regarding their symptoms and medications, prior to treatment.
The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically compromised situation, medical consultation may be needed prior to commencement of dental treatment.
I authorize the dentist to contact my physician.
Whom would you like us to contact in case of an emergency?