Signature will be recorded later.
Date: 7/23/2019Capitola Dental · P|831-475-2313 · 617 Capitola Ave, Capitola CA, 95010 · capitadental@gmail.com · www.capitoladental.comDo you have disease, condition, or problem not listed above that I should know about?Please list any medications or drugs you are currently taking:Please list any medications or drugs you are allergic to:Certification: I certify that the answers to the health questions are correct to the best of my knowledgePeriodontal (gum) surgery?Have you ever been treated for TMJ?Orthodontic treatment?Injury to your face, jaws or teeth?Oral surgery?Have you ever had:Have you noticed any loosening of your teeth?Do your jaws pop or lock when opening your mouth?Do you or have you had sinus trouble?Do you have sensitive teeth?Do you have difficulty in chewing your food?Do your gums bleed?Are you troubled with bad breath?Has fear of discomfort kept you from regular visits?Have you been having any specific problem?DOB:First Name:Last Name:Dr. Robert C. Schellentrager DMD General and Cosmetic DentistryDental History