Adult Health History Form
Full Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
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SS#
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How do you feel about saving your teeth?
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(Not important) 1
2
3
4
5
6
7
8
9
(Very important) 10
How would you evaluate your smile?
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(Ugly) 0
1
2
3
4
5
6
7
8
9
(Beautiful) 10
Medical health History:
Do you have, or have you had, any of the following? (Check all that apply)
Heart Problems
Blood Problems
Allergy Problems
Women
Women: If pregnant, how many weeks
Intestinal Problems
Bone or Joint Problems
Which joint was replaced
When was replacement
Diabetes
During the past 12 months, have you taken any of the following?
Other
If you drink alcohol, how much?
If you smoke, how much?
Are you allergic, or have you reacted adversely to any of the following? Please check all that apply.
List all the medications you are taking currently.
Signature
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Today's Date
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Month
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Day
Year
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Submit
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