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Health History Form
First / Last / Middle
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Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the the question)
Dental information For the following questions , please mark (X) your responses to the following question.
Medical information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
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WOMEN ONLY Are you:
Allergies Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.
Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
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Signature of Patient/Legal Guardian:

Signature of Dentist: