Forms for health history  

& Dental Information

 

In order to allow us to provide appropriate and outstanding dental care for you we need some information about your health

 

Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate dental care for you. Julington Dental does not use this information to discriminate.
This questionnaire from - American Dental Association, www.ada.org  - is a general health history form including dental information.

You will have to answer questions such as:
If you are Allergic to anything
If you use tobacco (smoking, snuff, chew, bidis)
If you have or have not had any disease listed
If your gums bleed when you brush or floss
If you ever had orthodontic (braces) treatment
If you brux or grind your teeth
If a physician or previous dentist recommended that you take antibiotics prior to your dental treatment

Adult Health History Form	Childrens' Health History Form