Medical History Questionnaire

Full Name*

Address*

Home Phone*

Work Phone

Mobile Phone

Email*

Date of Birth (MM/DD/YYYY)*

Health Insurance*

Who referred you to our office?*

When was your last dental visit?*

What has been your concern with previous dental visits?*

Are you being treated for a medical condition?*

Who is your doctor?*

Are you taking any medications or supplements at present, both prescribed or
over the counter? (Please List)*

Do you have, or have you ever had, any of the following medical conditions? (Hold down Ctl & click to pick multiple conditions)
	Additional Information

Please list all known allergies*

Do you smoke?* Yes No

For females, are you pregnant or undergoing fertility treatment? Yes No

PORUR TOOTH CENTRE