Medical History

Are you pregnant?


Taking birth control pills?

Indicate which of the following you have had, or have at present? (Check all that apply).

Jaw Pain

Do you smoke?

Do you use alcohol?

Do you use recreational drugs?

Have you had surgery or been hospitalized in the last 5 years?

Contact Us

Berkeley Dental Care

1752 N. Taft Ave

Berkeley, IL   60163


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