909-383-8931

PATIENT HEALTH HISTORY FORMS

Our friendly staff is eager to assist you in achieving lifelong dental health in a welcoming environment. For a streamlined start to your treatment, download and complete these forms. Bringing them to your appointment will expedite the process.

PATIENT HEALTH HISTORY

(Please fill out as completely as possible)

Please list all the names and phone numbers of the physicians who are currently providing you care:

For the following questions, circle Yes or No. Your answers are for our records only and will be confidential. Please note that during your initial visit, you will be asked some questions about your response. Our team may ask additional questions concerning your health.

Are you taking any of these medications?

Please list any medications you are currently taking and dosages:

Please list any dietary or herbal supplements you are taking and for what purpose:

T.M.D.

WOMEN

ABNORMAL BLOOD PRESSURE?

(PLEASE CIRCLE)

ARE YOU ALLERGIC OR HAVE YOU HAD A REACTION TO:

(PLEASE CIRCLE)

DIABETES:

If so, please answer questions below.

TOBACCO, ALCOHOL, DRUGS:

909-383-8931

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