• CHRONOLOGICAL HEALTH HISTORY WORK SHEET

  • The chronological health history is a very important part of this form. Please take your time to thoroughly complete this worksheet. After you have fully completed it, you will then transfer this information to the next page. Make sure you transfer the information in chronological order (i.e.: what happened first, second, third and so on.) The patient and physician can often get a much clearer view of the present condition when they have the information arranged in this manner.

  • Dental Work

    (include fillings as a child and adult, braces, root canals, extractions - especially wisdom teeth, trauma, periodontal disease, etc.)

     

  •  

  • Illnesses, Infections & Symptoms

    (include flu, throat & ear infections, tonsils, swollen lymph nodes, rashes, unexplained symptoms, etc.)

     

  •  
  •  
  • Should be Empty: