DENTAL HEALTH HISTORY QUESTIONNAIRE

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DENTAL HEALTH HISTORY QUESTIONNAIRE

All answers contained in this questionnaire are strictly confidential and will become part of your dental record.


DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING


WOMEN


List your prescribed drugs and over-the-the-counter drugs, such as vitamins and inhalers.


List any allergies to medications.


List any other medical problems/conditions that were NOT mentioned above:



THANK YOU FOR CHOOSING ACCELHEALTH!