3. Date of your last physical exam
6. DO YOU HAVE OR HAVE YOU EVER HAD
7. ARE YOU USING ANY OF THE FOLLOWING
8. ARE YOU ALLERGIC OR HAVE YOU HAD AN ADVERSE REACTION TO
15. Please list any and all Medications taken, including Prescription Medication, over the counter medications, herbal or holistic remedies, vitamins or minerals: (if not enough space please use back of this form to list all that you are taking):
If You are using oral contraceptives, it is important that you understand that antibiotics (and other medications) may interfere with the effectiveness of oral contraceptives. Please consult with your physician for further guidance.
I certify 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 have had the opportunity to discuss my Health History with my doctor. 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.
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