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Okemos Family Dentistry

Health History


(Pre-med required?
/ )

(Type 1 / Type 2)
A1C & date

(Treated with bisphosphonates?
/ )

Signature of patient

Signature of doctor

Current medications

  • Implants
  • Dentures
  • Partials
  • Extractions
  • Orthodontics
  • Periodontal Surgery
  • History of scaling and root planning
  • TMJ
  • Occlusal guard
  • Sleep appliance to treat sleep apnea
  • Tooth sensitivity
/