Auden Park Family Dentistry
First Name
Last Name
Date of Birth
Has there been any change in your health, such as any serious illnesses, hospitalization or new allergies?
YesNo
If yes, please specify
Are you taking any new medications or has there been any change in your medications?
Have you had a new or change in existing health condition.
Heart disease?
Blood thinners?
Diabetes?
Joint replacement?
Comments
Have you changed your family doctor or receiving care from specialist?
If yes please provide name and contact number of the doctor
When was your last medical checkup?
Were any problems identified?
If yes, please explain
For women only: Are you breastfeeding or pregnant?
If pregnant, what is the expected delivery date?
Your Signature
Date
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