Adult Patient Information



ADULT HISTORY PATIENT INFORMATION/CLINICAL HISTORY


Spouse Information








Please list any other significant information regarding your medical history

FEMALE PATIENTS:

DENTAL HISTORY:

Do you have any of the following habits?

We recognize that patients sometimes have concerns that may not be addressed by the questions in this Clinical History Form. Please feel free to include any additional information regarding your clinical history.

I understand that the above medical and dental information is correct. If there are any changes to my clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for a clinical examination.