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medical history
Patient Name
Date
Telephone
Referred By
Patient Email
Please list any medications you are currently taking:
Briefly describe any allergies or reactions you've had to medication:
Have you ever been hospitalized for serious illness or surgery? If so, briefly describe:
Please list the name of your physician and the date of your last physical examination:
Do you smoke?
Have you ever had heart disease, high blood pressure, diabetes, kidney, hepatitis ABC, epilepsy?
Have you experienced any chest pains, dizziness or fainting?
Have you had any injury, surgery, or radiation to the face or jaws?
Women - are you pregnant or taking oral contraceptives?
Dental history questionnaire
Have you seen a periodontist before?
What is the main reason for your appointment with us?
Will you be bringing x-rays with you?