In-Home Medical History

Please fill in the following medical history questions for yourself and for those who are receiving an exam.

Last Name

Phone number associated with Dentacōr

Indicate the names of those receiving exams today:

Have you or anyone receiving and exam experienced a major change to health within the past year?

Yes

Prefer Not To Answer

If yes, list who and what below:

Are you or anyone receiving and exam under the care of a physician or receiving ongoing medical care?

Yes

Prefer Not To Answer

If yes, list who and what below:

Name of Physician

Date of last medical visit: