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Date of Birth

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Health Information

In the following questions, check YES or NO, whichever applies. Your answers are for our records only and will be considered confidential.

Are you in good health?
Has there been any change in your general health within the past year?
Are you now under the care of a physician?
YesNo
Have you had any serious illness, operation, or been hospitalized?
YesNo
Have you had or do you now have any of the following:
Are you allergic or have reacted adversely to:
Are you taking any drug or medicine, including aspirin, now?
YesNo
Have you ever had Radiation Therapy or are you regularly exposed to x-rays?
YesNo
Are you wearing contact lenses?
YesNo
Women: are you pregnant or nursing?
YesNo
Have you had any serious trouble associated with any previous dental treatment?
YesNo
Do you have disease, condition, or problem not listed above that you think I should know about?
YesNo

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