Medical History Form

Medical History

Indicate which of the following conditions you have or have had. By checking the box it will indicate a "YES" response, leaving blank will indicate a "NO" response.
If any conditions or alerts selected above need further clarification, please describe below:
Do you take antibiotic premedication for your dental visits?*
If yes, please explain in the box provided below.
What is your estimate of your general health?
Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.
List all medications (prescription and non-prescription) including regular doses of aspirin: