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Medical History Form

Medical History

"*" indicates required fields

Current physical health is :*
Are you allergic to any of the following?

Do you have or have you experienced any of the following?

Abnormal Bleeding*
Drug Abuse*
Memory Loss*
Acid Reflux*
Emphysema*
Mitral Valve Prolapse*
Alcohol Abuse*
Epilepsy*
Occlusal Appliance*
Arthritis*
Glaucoma*
Pacemaker*
Artificial Joints*
Headaches*
Psychiatric Care*
Artificial Valves*
Heart Murmur*
Radiation Treatment*
Asthma*
Heart Surgery*
Rheumatic Fever*
Blood Transfusion*
Hepatitis*
Sinus Problems*
Cancer*
HIV+/AIDS*
Snoring/Sleep Apnea*
Chemotherapy*
High Blood Pressure*
Stroke*
Congenital Heart Defect*
Hearing Impaired*
Thyroid Problems*
Depression*
Kidney Problems*
Tuberculosis (TB)*
Diabetes*
Liver Disease*
Ulcers*
Anxiety*
High Cholesterol*
Vertigo*
Autism*

Women :

Are you happy with the appearance of your smile?*
Consent*
*
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Dentist - RiverRock DDS

RiverRock Dental in Shakopee, MN is a multi specialty dental clinic. Our dentists, Dr. Todd Christianson and Dr. Nathan Hanson hold over decades of collective clinical expertise to provide quality specialized dental care at affordable price. Each member of our team is dedicated to ensuring that our patients are well-informed and comfortable at all times. At RiverRock Dental, we will never begin a treatment or procedure until all of your questions have been answered and you feel relaxed and at ease. To give you the best possible services and results, we are committed to continual education and learning. Being member of various dental association’s helps us to stay abreast of the changes and recommendations for our profession.

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