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HEALTH HISTORY FORM
General Information
Contact Information
MYFAMILY ORTHODONTICS
Health History Form
Page 1 of 6
Medical Information Part I
Dental Information I
MYFAMILY ORTHODONTICS
Dental Information II
Health History Form
Page 2 of 6
Medical Information Part II
MYFAMILY ORTHODONTICS

Medical Information II (continued)

MYFAMILY ORTHODONTICS

Medical Information Part II (continued)

Health History Form
Page 3 of 6
MYFAMILY ORTHODONTICS

Medical Information Part II (continued)

For Women Only

Medical Information Part III
MYFAMILY ORTHODONTICS

Medical Information Part III (continued)

Health History Form
Page 4 of 6
MYFAMILY ORTHODONTICS
Medical Information Part IV
Health History Form
Page 5 of 6
MYFAMILY ORTHODONTICS

Medical Information Part IV (continued)

MYFAMILY ORTHODONTICS

Medical Information Part IV (continued)


Signature of Patient/Legal Guardian

Signature of Dentist

Health History Form
Page 6 of 6