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Medical History
Patient Name
Birth Date
Dental History
What is the reason for your visit?
When was your last visit to a dentist?
Have past dental experiences been satisfactory?
How do you feel about the appearance of your teeth?
Do you have or have you had any of the following?
Medical History
Do you have or have you had any of the following?
Physician:
Phone Number:
Date of last physical exam:
Please list all medications you are currently taking as well as over-the-counter medicines, herbal remedies, vitamins, homeopathic remedies:
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Allergies/ reaction to medications, or other allergies?
(Women) Are you pregnant?
Nursing?
Taking birth control pills?
Are you presently under a physicians care?
Explain
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Please describe any impending operations, recent injuries, or other information the dentist should be aware of:
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