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Family History Discovery
Patient Name
*
First Name
Last Name
Please choose any condition that applies to your parents:
Heart Disease
Stroke
High Blood Pressure
Heart Attack
Use Dentures
Pre-term Birth
Gum Disease
Tooth Loss
Diabetes
Are both of your parents still alive?
*
Yes
No
At what age were they diagnosed with these conditions?
Do you recall your parents taking medications?
*
Yes
No
Do you have siblings?
*
Yes
No
Are they also suffering from the same symptoms?
*
Yes
No
To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my Medications change, I will inform the dentist and the staff at the next appointment without fail.*
*
Agree
Submit
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