Medical History Update
We would like to update your medical records at this time to help us provide the best possible care for you. Your oralhealth is directly linked to your overall health. Please help us by completing this information. Thank you.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
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1956
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1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Did Your Emergency Contact Change?
In case of an emergency, who should we call?
Name
*
Relationship to you
*
Home Phone Number
*
Please enter a valid phone number.
Work Phone Number
*
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
AIDS/ HIV
*
Yes
No
Allergic to
*
Yes
No
If "Yes" please explain
*
Anemia
*
Yes
No
Angina Pectoris
*
Yes
No
Arthritis
*
Yes
No
Artificial Heart Valve
*
Yes
No
Artificial Joints
*
Yes
No
Asthma
*
Yes
No
Blood Disorder
*
Yes
No
If "Yes" please explain
*
Bronchitis
*
Yes
No
Cancer
*
Yes
No
Circulation problems
*
Yes
No
Congenital Heart Lesions
*
Yes
No
Crohn’s Disease
*
Yes
No
Diabetes
*
Yes
No
*
Type I
Type II
Dizziness
*
Yes
No
Emphysema
*
Yes
No
Epilepsy
*
Yes
No
Excessive Bleeding
*
Yes
No
Fainting
*
Yes
No
Glandular disorders
*
Yes
No
Glaucoma
*
Yes
No
Head Injuries
*
Yes
No
Heart Disease
*
Yes
No
Heart Murmur
*
Yes
No
Heart Rhythm disorder
*
Yes
No
Heart Surgery
*
Yes
No
Hepatitis
*
Yes
No
*
A
B
C
High Cholesterol
*
Yes
No
Hyper/hypo Glycemia
*
Yes
No
Inflammatory bowel disease
*
Yes
No
Mitral Valve Prolapse
*
Yes
No
Migraines
*
Yes
No
Blood Pressure
*
Yes
No
*
High
Low
Jaundice
*
Yes
No
Kidney Disease
*
Yes
No
Liver Disease
*
Yes
No
Lung Disease
*
Yes
No
Lupus
*
Yes
No
Malignant Hyperthermia
*
Yes
No
Mental Disorder
*
Yes
No
Nervous System Disorder
*
Yes
No
Organ Transplant/Medical Implant
*
Yes
No
Pacemaker
*
Yes
No
Radiation Treatment
*
Yes
No
Respiratory Problems
*
Yes
No
Rheumatic Fever (Scarlet Fever)
*
Yes
No
Sickle Cell Disease
*
Yes
No
Sinus Problems
*
Yes
No
Smoking
*
Yes
No
Stomach problems
*
Yes
No
Stroke
*
Yes
No
Thyroid Disorder
*
Yes
No
Tuberculosis
*
Yes
No
Venereal Disease
*
Yes
No
Ulcers
*
Yes
No
Usual Blood Pressure
*
(if known)
Women Only
Are you currently Pregnant?
*
Yes
No
Due Date
*
-
Month
-
Day
Year
Date
Are you under the care of a Medical Specialist?
*
Yes
No
Type
*
Name
*
Medications - Please List Your Regular Medications Below
Sign below to confirm that the above information is accurate, to the best of your knowledge.
Signature
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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