Medical History Page 4
ADVERTISEMENT
1
2
3
4
5Tobacco
________________________________________________________________________
__
Alcohol
________________________________________________________________________
___
Drugs
________________________________________________________________________
____
Are You: No Yes
Hearing impaired:
____________________________________________________________________
Visually impaired:
____________________________________________________________________
Other disabilities:
_____________________________________________________________________
Are you aware that there is a detrimental relationship between gum disease and systemic
diseases such as Diabetes
and Heart disease?
_____________________________________________________________________
Women: No Yes
Are you pregnant? ___________________________________________ Due Date:
________________
Are you taking hormone replacement? _________________Type
_______________________________
Are you taking birth control pills? ____________________ Type
_______________________________
Patient’s signature: _____________________________________________________
Date: _____________
Doctor’s notes:
________________________________________________________________________
_____
________________________________________________________________________
__________________
________________________________________________________________________
_______________________________
________________________________________________________________________
______________________________
________________________________________________________________________
__________________
________________________________________________________________________
__________________
________________________________________________________________________
__________________
________________________________________________________________________
________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical