Patient Medical Update Form

Patient Medical Update Form

Please submit this form at least 24 hours before your appointment. If you cannot submit the form due to technical difficulties, please let us know before your appointment. Thank you!

Today's Date

Date

Name

Only fill out the sections that have changed.

Address

Street Address Line 2

City. State. Zip Code

Home Phone

Format: (000) 000-0000.

Email

example@example.com

Work Phone

Format: (000) 000-0000.

Can we email or text you to confirm your appointments?

If yes, choose where you would like to receive confirmation messages.

Cell Phone

Format: (000) 000-0000.

What is the best way to reach you in case of an emergency?

Primary Care Physician Name

Primary Care Physician Phone

Format: (000) 000-0000.

Pharmacy Name

Pharmacy Phone

Format: (000) 000-0000.

Emergency Contact Name

Emergency Contact Phone

Format: (000) 000-0000.

Primary Dental Insurance Company

Subscriber Name

Subscriber DOB

Subscriber ID

Group Number

Employer

Secondary Dental Insurance Company

Subscriber Name

Subscriber DOB

Subscriber ID

Group Number

Employer

Please update the sections of your medical history that have changed.

Anemia

Arthritis

Artificial Bones/Joints

Artificial Heart Valve

Asthma

Back Problems

Bleeding/Clotting Problems

Blood Disease

Blood Transfusion

Cancer - Chemotherapy

Chemical Dependency

Circulatory Problems

Cold Sores

Cough Up Blood

Cough, Persistent

Diabetes

Eating Disorder

Epilepsy

Fainting Spells

Glaucoma

HIV + AIDS

Head/Neck Injury

Headaches

Heart Murmur

Heart Problems

Hemophilia

Hepatitis

High blood pressure

Jaw pain

Kidney problems

Liver diseases

Mitral Valve Prolapse

Nervous Problems

Pacemaker

Psychiatric Problems

Radiation Therapy

Respiratory Problem

Rheumatic Fever

Scarlet Fever

Shortness of breath

Sinus problems

Steroid treatments

Stroke

Swollen feet/ankles

Thyroid problems

Tobacco habit

Tonsilitis

Tuberculosis

Ulcers

Venereal disease

Allergies: Aspirin

Allergies: Codeine

Allergies: Dental Anesthetics

Allergies: Erythromycin

Allergies: Jewelry

Allergies: Latex

Allergies: Metals

Allergies: Penicillin

Allergies: Tetracycline

Any other allergies we should know about? Please list them below.

Do you smoke or use tobacco?

WOMEN ONLY: Are you taking birth control?

WOMEN ONLY: Are you pregnant?

If yes, how many weeks?

WOMEN ONLY: Are you nursing?

PLEASE LIST ALL CURRENT MEDICATIONS AND DOSAGES

Have you had any serious illnesses or operations?

If yes, please describe:

Were you advised premedication for dental treatment? If so, please list the prescription below

Signature

Date