Health History Form
Patient Information
Name
First Name
Last Name
If the patient is a minor, please complete the following section:
School
Grade
Sports/Hobbies/Interests:
Dental History
Dentist
Practice Name
City
Phone Number
Please enter a valid phone number.
Date Last Visited
-
Month
-
Day
Year
Date
Medical History
Please list any medications that you are currently taking:
Please list any allergies you may have:
Please describe any other medical condition(s)/surgeries we should be informed of:
Patient Signature
Date
-
Month
-
Day
Year
Date
Guardian Signature (if applicable)
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: