Health History Form


Dental Information

For the following questions, please select your responses to the following questions


Medical Information

Please select your response to indicate if you have or have not had any of the following diseases or problems

Joint Replacement

Women Only


Allergies

Are you allergic to or have you had a reaction to: (To all yes responses, specify type of reaction)


Please select your response to indicate if you have of have not had any of the following diseases or problems.

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD


NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful
health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries
set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action
they take or do not take because of errors or omissions that I may have made in the completion of this form.

HOLLAND FAMILY DENTISTRY OFFERS A NUMBER OF COSMETIC, PREVENTATIVE, GENERAL, AND SPECIALIZED DENTAL SERVICES AT OUR OFFICE IN HOLLAND.

Learn more about the services we offer and the conditions we treat by reading on and scheduling an appointment!