Slone Dental Medical History Update
Patient's Name
*
Mr.
Mrs.
Ms.
Prefix
First Name
Middle Initial
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Name
Gender
*
Male
Female
Family Status
*
Married
Single
Child
Other
Date of Last Visit
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Social Security Number
*
Best time to call
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone & Ext.
Please enter a valid phone number.
Fax Number
Emergency Contact
First Name
Last Name
Relation
Emergency Phone
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health History & Medical Alerts
Please select all that apply to you:
Allergy- Aspirin
Allergy- Keflex
Allergy- Penicillin
Amelogenesisimperfec
Artificial Joints
Blood Disease
Breathing Problems
Cold Sores
Dialysis
Fainting
Heart Defect
Hepatitis
Kidney Disease
Multiple Sclerosis
OCD
Psychiatric Tx
Rheumatic Fever
Allergy- Augmentin
Allergy- Latex
Allergy- Seasonal
Anemia
Aspirin Daily
Blood Thinners
Bruise Easily
COPD
Dizziness
Fever Blisters
Heart Disease
High Blood Pressure
Liver Disease
MVP
Other
PTSD
Rheumatism
Allergy- Cephadyn
Allergy- Omicef
Allergy- Sulfa
Arthritis/Gout
Asthma
Blood Transfusion
Cancer
Diabetes Type II
Epilepsy/Seizures
Glaucoma
Heart Murmur
HIV/AIDS
Lupus
Nervous Disorders
Pregnancy
Pulm Lung Disease
Sinus Problems
Allergy- Codeine
Allergy- Other
Allergy- NSAIDS
Artif. Heart Valve
Bisphosphonates
Breast Feeding
Chemotherapy
Diabetes (Insulin)
Excessive Bleeding
Head Injuries
Heart Pacemaker
Hizentra
Mental Disorders
No Epinephrine
Pre-Medicate
Radiation Treatment
Stomach/Intestinal
Rheumatic Fever
Stroke
Tumors/Growths
Rheumatism
Swelling of Limbs
Ulcerative Colitis
Sinus Problems
Thyroid Disease
Ulcers
Stomach/Intestinal
Tuberculosis
Venereal Disease
Other
Have you had any medical changes since your last appointment?
*
Yes
No
List all medications that you are currently taking:
Name of your preferred pharmacy:
Submit
Should be Empty: