Although dental personnel primarily treat the area in and around the 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 confidential questions.
    Please check ones that apply.
    Please check ones that apply.
  • If you have had any serious illnesses not listed above or put yes for any questions please explain here.
  • 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 responsibility to inform the dental office of any changes in medical status.
  • Date Format: MM slash DD slash YYYY