Established Patient – Dental Medical and History Update
Patient Name:
*
First Name
Middle Name
Last Name
Phone #:
Format: (000) 000-0000.
Email
example@example.com
Any changes to Dental insurance?
Yes
No
If yes, please explain
Have there been any changes in your health since your last appointment (including pregnancy)
Yes
No
If yes, please explain
Have you had any major health issues, surgeries or hospitalizations since your last visit?
Yes
No
If yes, please explain
Have you had any major health issues, surgeries or hospitalizations since your last visit?
Yes
No
If yes, please explain
Are you taking any current medications and or supplements – prescription and or non-prescription? (List below)
Yes
No
If yes, please explain
Do you have any allergies to medications, foods or latex?
Yes
No
If yes, please explain
Do you use tobacco products?
Yes
No
If yes, please explain
Current Medications:
Patient Signature
*
Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: