Medical History – Dentacōr

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

Have you experienced a major change to health within the past year?

Yes

No

Prefer Not To Answer

If yes, list who and what below:

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

Yes

No

Prefer Not To Answer

If yes, list who and what below:

Name of Physician

Date of last medical visit: