Medical and Dental Health History



Medical Health


Do you have or have you ever had any of the following? (Please check all that apply)

Are you allergic to or have you reacted adversely to any of the following? (Please check all that apply)

Are you taking or have you ever taken any of the following? (Please check all that apply)


Female


List of current medications, including both prescription and over the counter, you are taking


Dental Health