Health History

WOMEN ONLY Are you:

Allergies. Are you allergic to or have you had a reaction to:

To all yes responses, specify type of reaction.

Please indicate if you have or have not had any of the following diseases or problems.

Congenital heart disease (CHD)

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction.

I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.