Aesthetics & Prosthodontics Dentistry, LLC
849 Lincoln Avenue
Glen Rock, NJ 07452

Medical History

How would you describe your present medical health?

Excellent

Good

Fair

Poor

Do you have a personal physician? (Physician name/town):

Date of Last Physical:

Date of Last Blood Test:

Are you currently under the care of a specialist? (Physician name/town):

Are you currently taking any prescription or over the counter drugs? (List all drugs):

For women:

Are you taking birth control pills?

Yes

Are you pregnant?

Yes

Are you nursing?

Yes

Do you smoke?

Yes

If yes, describe type and quantity:

Have you ever had:

Antibiotic (penicillin)

Local Anesthetic (Novocaine)

Codeine

Please list any other allergies:

Please list any other medical condition(s) or surgeries you have had:

Patient Validation:

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