Health History

Patient Information
Emergency Contact Information
Dental Information
 
Is your mouth dry?
Have you had periodontal (gum) treatment?
Have you had orthodontic treatment?
Have you had any problems with dental treatment?
Do you have clicking, popping or discomfort in the jaw?
Do you grind your teeth/ or wear a bruxism?


Medical Information
 
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Allergies

Aspirin Codeine Sulfa Local Anesthetic Demerol Penecilin Latex Environment

Health History
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