Updated Medical Health History
Name
*
First Name
Last Name
Are you allergic to any drugs or medications? If yes, please List
Yes
No
Drug Allergies
Do you have artificial joints such as knee or hip replacements? If yes, please list with date:
Yes
No
Surgery Type
Date
-
Month
-
Day
Year
Date
Have you been told you need to premedicate with an antibiotic prior to your Dental appointment
Yes
No
Have you had any heart surgeries? If yes, please list with date:
Yes
No
Date
-
Month
-
Day
Year
Date
High blood pressure? If yes, please list medication:
Yes
No
Medications List
A heart ailment, including mitral valve prolapse or heart murmur?
Yes
No
Do you have Diabetes?
Yes
No
Do you have Rheumatic fever?
Yes
No
Have you ever had any radiation treatment?
Yes
No
Do you have Hepatitis? If yes, please list type:
Yes
No
Type of Hepatitis
Do you have epilepsy, convulsions, or seizures?
Yes
No
Do you have any pain in or near your ears?
Yes
No
Are you pregnant? If yes, how many months?
Yes
No
Months Pregnant
One
Two
Three
Four
Five
Six
Seven
Eight or More
Are there any other conditions we should be aware of?
Are you presently taking drugs or medications not listed above for any other medical condition? If yes, please list, if not enter "None":
*
List Medications
Is there anything you would like to change about your teeth since the last visit?
Do you want whiter teeth?
Yes
No
Patient Signature:
*
Submit
Should be Empty: