Family History Discovery | Naples Dentist

Patient Name*

Family Medical History

Please choose any condition that applies to your parents:

Heart Disease
Stroke
High Blood Pressure
Heart Attack
Use Dentures
Pre-term birth
Gum Disease
Tooth Loss
Diabetes

Are both your parents still alive?*

Yes
No

What ages did they pass?

At what age were they diagnosed with these conditions?

Do you recall your parents taking medications?*

Yes
No

For how long?

Do you have siblings?*

Yes
No

Are they also suffering the same symptoms?*

Yes
No

To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my Medications change, I will inform the dentist and the staff at the next appointment without fail.*

Agree