top of page
gfnfgnfgm.png
69013da45cc02_69013da45cc00.jpg

Medical History Forms

PATIENT INFORMATION

Date of Birth
Month
Day
Year
Your Gender
Male
Female
Other

MEDICAL INFORMATION

Are you under a physician’s care now?
Yes
No

MEDICAL HISTORY

Please indicate if you have or have ever had any of the following:

MEDICATIONS & ALLERGIES

Are you allergic to any medications?
Yes
No

DENTAL HISTORY

Do your gums bleed when you brush or floss?
Yes
No
Do you have pain in your teeth or jaw?
Yes
No
Do you grind or clench your teeth?
Yes
No
Do you smoke or use tobacco products?
Yes
No
How often do you brush?
Yes
No
Floss?
Yes
No
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
bottom of page