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

Email

example@example.com

Work Phone

Can we email or text you to confirm your appointments?*

YesNo

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

TextEmailBoth

Cell Phone

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

Primary Care Physician Name

Primary Care Physician Phone

Pharmacy Name

Pharmacy Phone

Emergency Contact Name

Emergency Contact Phone

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

YesNo

Arthritis

YesNo

Artificial Bones/Joints

YesNo

Artificial Heart Valve

YesNo

Asthma

YesNo

Back Problems

YesNo

Bleeding/Clotting Problems

YesNo

Blood Disease

YesNo

Blood Transfusion

YesNo

Cancer - Chemotherapy

YesNo

Chemical Dependency

YesNo

Circulatory Problems

YesNo

Cold Sores

YesNo

Cough Up Blood

YesNo

Cough, Persistent

YesNo

Diabetes

YesNo

Eating Disorder

YesNo

Epilepsy

YesNo

Fainting Spells

YesNo

Glaucoma

YesNo

HIV + AIDS

YesNo

Head/Neck Injury

YesNo

Headaches

YesNo

Heart Murmur

YesNo

Heart Problems

YesNo

Hemophilia

YesNo

Hepatitis

YesNo

High blood pressure

YesNo

Jaw pain

YesNo

Kidney problems

YesNo

Liver diseases

YesNo

Mitral Valve Prolapse

YesNo

Nervous Problems

YesNo

Pacemaker

YesNo

Psychiatric Problems

YesNo

Radiation Therapy

YesNo

Respiratory Problem

YesNo

Rheumatic Fever

YesNo

Scarlet Fever

YesNo

Shortness of breath

YesNo

Sinus problems

YesNo

Steroid treatments

YesNo

Stroke

YesNo

Swollen feet/ankles

YesNo

Thyroid problems

YesNo

Tobacco habit

YesNo

Tonsilitis

YesNo

Tuberculosis

YesNo

Ulcers

YesNo

Venereal disease

YesNo

Allergies: Aspirin

YesNo

Allergies: Codeine

YesNo

Allergies: Dental Anesthetics

YesNo

Allergies: Erythromycin

YesNo

Allergies: Jewelry

YesNo

Allergies: Latex

YesNo

Allergies: Metals

YesNo

Allergies: Penicillin

YesNo

Allergies: Tetracycline

YesNo

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

Do you smoke or use tobacco?

YesNo

WOMEN ONLY: Are you taking birth control?

YesNo

WOMEN ONLY: Are you pregnant?

YesNo

If yes, how many weeks?

WOMEN ONLY: Are you nursing?

YesNo

PLEASE LIST ALL CURRENT MEDICATIONS AND DOSAGES

Have you had any serious illnesses or operations?

YesNo

If yes, please describe:

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

Signature

Date