harborsquaredental-Health History

Patients Name:

Date of Birth

Date

Physician’s Name

Physician’s Phone#

Please enter a valid phone number.Format: (000) 000-0000.

Please list all medications you are currently taking (including herbal/natural remedies):

YesNo

Please list reason

Please circle if you have or have had any of the following:

SeizuresEpilepsyHistory of head injuryOther:

Arthritis/ RheumatoidBack/Neck PainJoint replacement

TypeStage: I II III IVIn RemissionChemotherapy

Please list any other medical conditions you have ever had that are not listed above.

YesNo

please describe

Please describe your reaction:

Health History