• HEALTH HISTORY

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  • Answer all questions by select Yes (Y) or No (N). All responses are kept confidential

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  • DO YOU HAVE OR HAVE YOU EVER HAD

  • ARE YOU USING ANY OF THE FOLLOWING:

  • ARE YOU ALLERGIC TOOR HAVE YOU HAD AN ADVERSE REACTION TO:

  • FOR WOMEN ONLY:

  • If you are using Oral Contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of medication is completed.

  • I understand the importance of a truthful and complete Health History to assist my dentist in providing the best care possible. I have had the opportunity to discuss my Health History with my dentist.

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  • Clear
  • Doctor's initials

  • Should be Empty: