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Health History

University Dental Care

112 W Foster Ave, Ste 201,
State College, PA 16801
8142348224

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Health History( * mandatory to fill )
Health History( * mandatory to fill )
  •  Yes
  •  No
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  •  Yes
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  •  Yes
  •  No
  •  Very
  •  Somewhat
  •  Not Interested
  •  Yes
  •  No

 

 

 

 

WOMEN ONLY: Are you

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

 

 

 

 

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

  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No
  •  Dk
  •  Yes
  •  No

 

 

 

 

Please select your response to indicate if you have or have not had any of the following diseases or problems.

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

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

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
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  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
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  •  Yes
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  •  Yes
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  •  Yes
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  •  Yes
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  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

 

 

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

 

 

 

  •  Yes
  •  No
  •  Yes
  •  No

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

I certify that I have read and understood the above and that the information given on this form is accurate. I understand the importance of 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.

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