Patient Medical History

Patient Medical History

Date of last exam:

1. Are you having any dental concerns?

2. Are you under medical treatment now?

3. Have you been hospitalised for any reason?

4. Are you taking any medication?

5. Do you use tobacco products?

6. Do you use alcohol?

7. Do ou use controlled substance?

8. Are you allergic or had any reaction to the following:

Do you have any of the following?

9. Women only

Do you have any of the following?

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