Rockdental-Health History

Health History
Patient's Name

First NameLast Name
How would you rate your general health?
Are you under the care of a physician?
Please explain
Physician’s Name
Phone
Do you have, or have you ever had, any of the following (please mark all that apply):
Do you have any disease, condition or problem not listed above?
Please explain
Have you been hospitalized and/or had surgery?
Please explain
Please list all medications and supplements you are taking :
Are you allergic or sensitive to any of these medications:
Any other medications you are allergic or sensitive to?
Have you received the Covid-19 Vaccines?
Women: Are you pregnant?
Are you nursing?
Taking Birth Control Pills?
Comments/Remarks
Signature
Date

MonthDayYear
Date
Should be Empty: