Health History Form


    SelfOther
    Yes
    I do not have dental insurance
    Yes (describe):NO

    Yes, brushYes, flossNo
    times per day
    times per wk


    YesNo

    Yes, forNo
    years


    Yes, forNo
    years


    YesNo

    YesNo

    YesNo

    YesNo
    Yes (describe):
    No

    YesNo

    Interested in quitting? YesNo



    YesNo

    YesNo

    YesNo