Medical and Dental History
Please complete the following with the approximate age of occurrence:
Surgery
*
Toxic Profession Past or Present (artist, graphic designer, dental assistant etc.)
*
Injuries/Accidents Without Stitches
*
Major Psychological Trauma
*
Serious Infections/Diseases (pneumonia, mono, T.B, cancer, heart attack etc.)
*
Typical childhood vaccinations?
*
Yes
No
Long Periods on Prescription or Street Drugs, or Alcohol, or Cigarettes
*
Injuries/Accidents With Stitches
*
Long Visits or Lived In A Foreign Country Like India, Mexico, Africa etc.
*
Treated for parasites, infection?
*
Yes
No
Dental Intervention (root canals & extractions - please try to name & number tooth - refer to dental chart. Also, age of first silver amalgam filling braces, retainer, etc.)
*
Pregnancies/Births/Abortions/IUD's, B.C. pills, etc.
*
Medications/Allergies (Past or Present)
*
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