Medical History Update
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Any change in your medical history in the past 6 months?
Yes
No
If yes, please describe
Any hospitalizations/ surgeries in the past 5 years?
Yes
No
Do you usually take premedication prior to dental appointments?
Yes
No
List any medications and over-the-counter medications you take (if any)
Signature
Submit
Should be Empty: