MEDICAL HISTORY UPDATE

MEDICAL HISTORY UPDATE
Name

First NameLast Name
Preferred Name
Email Address
example@example.com
Best Number to Contact You
Please enter a valid phone number.Format: (000) 000-0000.
Primary Physician's name
Date of most recent visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What is your general health?
Address
Home Address Changes?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance
Insurance Changes?
Dental Insurance Company Name
Group Number
ID Number
Name of Insured
Relationship to Patient
Insured Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SS#/SIN
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical History

Please select yes if you currently have or previously had any of the following medical conditions.
Heart Murmur
Heart Disease/Attack
High Blood Pressure
Low Blood Pressure
Artificial Heart Valve / Pacemaker
Atrial fibrillation
Anemia or Blood Disorder
Prolonged bleeding / taking a blood thinner
Stroke
Date of Stroke
High Cholesterol
Emphysema/COPD
Tuberculosis
Asthma
Breathing or sleeping problems/apnea
Liver Disease
Kidney Disease
Dialysis
Last date of Dialysis

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hepatitis
Type of Hepatitis
Thyroid or Parathyroid Disease
Hormone Deficiency
Diabetes
List Most Recent A1C
Stomach or Duodenal Ulcer
Digestive Disorders (i.e. GERD/reflux)
Osteoporosis/Osteopenia
Bisphosphonate therapy (pill/injection/infusion)
Arthritis
Artificial Joints
Please list all artificial joints and date of surgery
Neurological Problems
Epilepsy / Seizures
Date of the last event

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Head or Neck Injuries?
Viral Infections and Cold Sores
STIs
HIV / AIDS
Cancer / Tumors
List Type of Cancer
Date of Diagnosis

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Radiation Treatment
Chemotherapy
Date of last radiation treatment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last chemotherapy treatment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Glaucoma
Psychiatric treatment
Depression
Anxiety Disorder
Alcohol/Drug dependency
Tobacco / Nicotine (ie cigarettes, vapes)
Date of Hepatitis Diagnose

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Any significant hospitalization for illness or injury
Reason for hospitalization for illness or injury
Date of hospitalization for illness or injury

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
FEMALE
Taking birth control pills
Currently Pregnant / Breastfeeding
MALE
Prostate Disorders
DO YOU HAVE AN ALLERGIC REACTION TO:
Latex
Penicillin / Amoxicillin
Aspirin / Ibuprofen / Acetaminophen
Sulfa
Erythromycin
Tetracycline
Codeine
Local anesthesia
Fluoride
Metals (gold, stainless steel)
List ALL other allergies. If no other allergies, type none
Please list ALL medication(s), dosage, and frequency prescribed to you and for what reason:

(including natural, herbal, or homeopathic products)
If you do not take any medications at this time, type none.
Any changes to your dental health since your last visit?
PHARMACY
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Patient's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Assignment & Release
I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by the dental office, I am obligated to pay said office in accordance with its credit terms and policy.
Patient's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

MEDICAL HISTORY UPDATE

Address

Dental Insurance

Medical History

FEMALE

MALE

DO YOU HAVE AN ALLERGIC REACTION TO:

Please list ALL medication(s), dosage, and frequency prescribed to you and for what reason:

PHARMACY

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Assignment & Release