MEDICAL HISTORY UPDATE
Please complete this form prior to your appointment
. Thank you.
Patient Name
*
First Name
Last Name
Date of Birth:
*
/
Month
/
Day
Year
Date
1. Any medical changes?
*
Yes
No
If yes, provide details.
2. Any recent hospitalizations/major surgeries?
*
Yes
No
If yes, provide details.
3. Allergic to any medications?
*
Yes
No
If yes, provide details.
4. Currently taking any medications?
*
Yes
No
If yes, provide details.
5. In the past two weeks, has the patient experienced any symptoms of fever, coughing, shortness of breath, loss of smell or taste?
*
Yes
No
If yes, provide details.
6. In the past two weeks, has the patient tested positive, been exposed or currently waiting on results for COVID-19?
*
Yes
No
If yes, provide details.
7. Consent for clinical pictures to be taken of mouth/teeth for patient records:
*
Yes
No
8. Are there any updates to your contact information (address/phone/email)?
*
Yes
No
Updated contacted info:
Primary questions or concerns:
Signature:
*
Clear
Date:
*
/
Month
/
Day
Year
Date
Name of Adult Accompanying Patient
*
Relationship to Patient:
*
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