Benjamin W. Young DDS MS
Adult Health History for NEW Patients (Part 1)
Yours answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you cannot remember specific details, please provide your best guess. If you are uncomfortable with a question, do not answer it.
Review of Symptoms
Other Health Issues
Main reason for seeing Dr. Young:
What are your dental health goals for the next year?
Are you in pain? If yes, how long?
Do Not Fill This Out