Health History

Patient Information

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Main Reason for Today's Visit:

Insurance

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Health History

The following information is essential for this office to provide dental care in a manner that is compatible with your general health. Your cooperation in providing accurate information is necessary to meet your dental needs safely and efficiently. Incorrect information can be dangerous to your health.

Health History

For the following, fill in the answer to each question in the space provided. If the question is not understood, you are not certain of the answer, or have any question, indicate so in the space, and discuss the matter with the doctor. All questions must be answered.

Please indicate the specific condition if you have ever had or been treated for:

Dental History

In respect to any previous dental treatment, please check if you:

NOTE: A change In your health status should be reported to the office at the earliest possible time.

To the best of my knowledge, the foregoing questions have been accurately answered. Permission To Release Health Information: I grant the right to the dentist to release health information obtained from me, and information about my dental treatment to third party payors, and/or other health practitioners.

Christopher G. Stuzynski, D.D.S.
111 Warren Rd. Suite 1A
Cockeysville, MD 21030
(410) 666-8383