Welcome to our office. Please allow us to get to know you better by completing the following questionnaire. Thank you.








Medical History: Do you, or have you ever had any of the following: Y= Yes, N= No, NA= Not Available

Women Only

Kids Only

Allergies or reactions to any of the following:

Are you taking any medication, nutrient supplements, herbal medications or non-prescription medicine? Please name and list reason:


Dental History


I h ave read, understood, the above questions and have answered to the best of my knowledge. I will not hold Mary Buatti Romeo, DDS, Karen Leavy, DDS, Scott Mateer, DDS, or David Hou, DDS responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will inform this practice.