Prior to your first appointment please fill out the following health history.

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Date of Birth:

Marital Status:

Are you under a physician's care now?

If yes, please explain:

Have you ever been hospitalized or had a major operations?

If yes, please explain:

Have you ever had a serious head or neck injury?

If yes, please explain:

Are you taking any medications, pills, or drugs?

If yes, please explain:

Do you take, or have you taken, Phen-Fen or Redux?

Are you on a Special diet?

Do you use tobacco?

Do you use controlled substances?

Women, are you :

Are you allergic to any of the following?

If yes, please explain:

Do you have, or have you had, any of the following?

Have you ever had any serious illness not listed above?

If yes, please explain:





© 2007 Edward Mitoma & Jessie Nakamura DDS Inc., 1552 Tracy Boulevard, Tracy, CA 95376 | 209.835.9111