Recall History Filll in the form First Name Last Name Email Phone Address Emergency Contact Name Emergency Contact Pharmacy Family Doctor Physician's Contact 1. Do you have any dental pain or discomfort? Yes No 2. Has there been any change in your health such as serious illnesses, hospitalizations or surgeries in the past year? If yes, please explain. Yes No 3. Allergies 4. Are you taking any medications? Yes No Not Sure / Maybe 5. Have you had any new heart problems diagnosed or had any change in an existing heart problems in the past year? Yes No Not Sure / Maybe 6. When was your last medical checkup? 7. Were any problems identified? If yes, please explain. Yes No Not Sure / Maybe For Women Only 1. Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date? Yes No Not Sure / Maybe Delivery Date 2. Are you taking birth control pills? Yes No Submit
