A complete medical history is very important to allow our dentists to make the best dental decisions for your dental health and overall well-being. Please fill out the following medical history information for the patient.  

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* 1. Patient Name

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* 2. Allergies

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* 3. If allergic, please explain:

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* 4. Current Medication Name (dose/reason if known).
Include Prescription Medicine, Over-the-counter Medicine and Herbals.
Write NONE if not taking any medications.

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* 5. Hospitalizations or surgical procedures in the patient's lifetime (date/reason).
Write NONE if no prior surgeries.

 
5% of survey complete.

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