CONFIDENTIAL HEALTH HISTORY
I. CIRCLE APPROPRIATE ANSWER(Leave blank if you do not understand the question)
VI. WOMEN ONLY
VII. ALL PATIENTS
The practice of dentistry involves treating the whole person. If the doctor determines that there may be a potentially medically-compromised
situation, a medical consultation may be needed prior to commencement of orthodontic treatment.
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely
and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or
any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.