Medical History Update
PATIENT'S NAME
*
First Name
Last Name
CELL
Please enter a valid phone number.
Format: (000) 000-0000.
EMAIL
example@example.com
Are you taking any pills, drugs, or medication? If applicable, please list these details below:
Do you have any prescription, drug or latex allergies? Or have you been warned against taking any drug or medication? If applicable, please specify:
When was your last medical checkup?
Have you travelled outside of the country recently? If yes, have you had any illness since or other symptoms such as a cough?
Have you had a problem with local anesthetic in the past?
Yes
No
Do you have a reaction to epinephrine?
Yes
No
Do you require pre-medication?
Yes
No
Do you take blood thinners?
Yes
No
Do you have or have you ever had any of the following (please select options below, if applicable):
Heart Attack/Heart Murmur
Hepatitis A/B/C
AIDS
Liver Disease
Stomach/Intestinal Problems
Drug Addiction
Lung Disease
Cancer
Joint Replacement/Implants
Venereal Disease
Tuberculosis
Kidney Disease
Mental/Nervous Disorder
Scarlet/Rheumatic Fever
Diabetes
Sinus Trouble
High or Low Blood Pressure
Epilepsy/Seizures
Anemia
Bleeding/Clotting disorder
Hyper/Hypo Glycemia
Arthritis/Rheumatism
Herpes
Asthma
Heart Condition
Weight Change
Infective Endocarditis
Prosthetic Cardiac Valve
Any Other Condition?
Do you have any respiratory diseases?
Yes
No
If yes please list
Do you smoke cigarettes?
Yes
No
If so how many daily?
Are you pregnant?
Yes
No
Are you breast feeding?
Yes
No
Have you been hospitalized, had surgeries or changes in your health in the past 5 years?
Yes
No
If yes please list
PATIENT'S SIGNATURE
DATE
/
Month
/
Day
Year
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