Medical History Update

Patient's Name:
DOB:

Accurate information about your health is important in planning your dental treatment. To ensure success of treatment and to promote your general health, all questions should be answered. If you are in doubt about a question, or how it relates to any condition you have had, or currently have please discuss it with our dental staff. All information willbe held in strict confidence.


Current Contact / Insurance Information

Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Dental Insurance Carrier:
Emergency Contact Name and Number

Medical History

PLEASE BRING A LIST OF ALL MEDICATIONS YOU ARE CURRENTLY TAKING

Do you, or have you ever had any of the following within the last 5 years?:

Abnormal bleeding from a cut
Abnormal heart condition
Diabetes / hypoglycemia
Heart Murmur
Allergies to local anesthetics
Allergies to metals
Anemia/Blood Disorder
Allergies to Medication
Please specify:
Do you have a condition that requires you to Pre-medicate?
Blood transfusion
Do you take blood thinners?
Do you use tobacco
What frequency:
Hepatitis Vaccine
Hepatitis
What type?:
High Blood Pressure
Mitral Valve Prolapse
Pacemaker
Prosthetic or artificial joints?
Please explain:
Respiratory Infection
Rheumatic Fever
Tested for HIV or AIDs
Test result:
Taking medications? Vitamin, Supplements?
Please list:

Females Only:

Are you pregnant
Taking HRT (hormones)
Taking birth control

Have you traveled outside the United States within the past yearor to another State in the last few month?

Where?:

Check the item's box if you've ever had:


Signature:
Date: