• Seaforth  Oral Surgery

    Seaforth Oral Surgery

    Confidential Health Questionnaire
  • IDENTIFICATION

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  • CONTACT

  • TODAY'S VISIT

  • HEALTH HISTORY

    Oral surgeons provide care to the region in and around your mouth. If you have health conditions involving other parts of your body, this may have a relationship with your dental health and could influence the type of care you will receive. You are helping your oral surgeon provide you with the best possible care by informing him of these conditions

  • GENERAL HEALTH

    Please check the appropriate response:

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  • TREATMENTS

  • HOSPITALIZATION

  • MEDICATION

  • ALLERGIES

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  • PROSTHESIS

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  • WOMEN ONLY

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  • PAST AND CURRENT CONDITIONS

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  • NOTES

  • SIGNATURE

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