Dental Health History

Which location will you be visiting?

Name

First NameLast Name

Date of Birth

Date

When was your last dental visit?

Date

Do you have:

Do you use any form of tobacco

Are you allergic to, or have you had any reaction to:

List any previous or current cancer(s):

List any previous major surgeries:

List any previous joint replacements:

Do you have, or have you ever had any of the following? (Check all that apply)

For women - check if you are:

Do you take a daily aspirin?

List all medications you are currently taking:

DENTAL HEALTH HISTORY