"Ignore your teeth, they'll go away".

    "You don't have to brush all your teeth, just the one's you want to keep".

 

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Health History

          Dr. Michael Robinson

                 Fellow in Academy of General Dentistry

                           McIntosh, Alabama  

            
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Alabama Dental Association

 

 

 

  "REDNECK PACIFIER"

HEALTH HISTORY QUESTIONNAIRE

 Name

  1. Have you been Hospitalized in the past 5 years?    yes  no
  2. Are you currently under a Doctor's Care?               yes  no        Physician/Telephone/Condition:                            
  3. Are you currently taking any medications ?             yes  no       List:                                                  

  4. Do you have or have you had any of the following? (check all that apply)                                                                                                 

 

 

 

 

 

 

 

 

 

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No representation is made that the quality of dental services to be provided is superior to the quality of services provided by other dentists.

Send mail to drmike@docktormike.com with questions or comments about this web site.
Copyright © 2002 R. Michael Robinson D.M.D.
Last modified: November 17, 2003