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  • GENERAL HEALTH QUESTIONNAIRE

  • CHECK YES OR NO (for every question)

  • Allergies to Medicines

  • Other Allergies

  • ANY PERSONAL OR FAMILY HISTORY OF UNUSUAL REACTIONS OR

    COMPLICATIONS FROM SURGERY OR ANESTHESIA?

  • For Women

  • (ANTIBIOTICS MAY INTERFERE WITH  THESE MEDICATIONS)

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Disclaimer

Information viewed on this website is for information purposes only and should not be viewed as delivery of dental or medical care. No diagnosis or treatment is being provided, nor any establishment of a Doctor/patient relationship by the use of this website. If you have questions, the information contained therein should be discussed with the surgeon.