Medical History Update Form

Medical History Update Form

Dentistry on Liverpool
Please complete the following questions to the best of your ability. All information is strictly confidential and is essential to providing you with the highest standard of dental care.
Title*
Given Name*
Last Name*
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Tel: Cellular*
Please enter a valid phone number.Format: (000) 000-0000.
Tel: Residence
Please enter a valid phone number.Format: (000) 000-0000.
Tel: Business
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Family Physician: Name*
Family Physician: Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
In case of Emergency, Please Notify:
Emergency Contact*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Is your physician currently treating you for any reason: *
When was your last visit to a physician?*
Reason:*
Do you have a joint replacement*
Date of surgery*
Have you been hospitalized in the past 12 months?*

YesNo
Are you presently taking any kind of medication?*

YesNo
Specify
a. Drug
Reason
b. Drug
Reason
c. Drug
Reason
d. Drug
Reason
e. Drug
Reason
f. Drug
Reason
Do you have any of the following allergies?*

PenicillinSulphaCodeineLatexErythromycinNone on the list
Any other allergies?
Do you smoke or use other tobacco products?*

YesNo
How much?
Do you presently, or have you ever had:

Chest pain or heart diseaseArthritisHigh blood pressureDiabetesHeart murmurThyroid problemsPacemaker or artificial valvesStomach or intestinal ulcersBlood disorders or anemiaEpilepsy or seizuresAsthmaHIV/AIDSOther lung or breathing problemsCancerHepatitisRadiation therapyOther liver or kidney problemsOsteoporosis
Have you ever had any illness not included above?*

YesNo
Specify
Women Only:
Are you pregnant?

YesNo
What is the expected delivery date?
Is there anything concerning your health your dentist should know about?
Patient (Parent, Guardian) Signature*
Date

MonthDayYear
Date
Should be Empty:

Medical History Update Form

In case of Emergency, Please Notify:

Women Only: