UPDATE Health History

UPDATE Health History

(EXISTING PATIENTS ONLY)
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Type*
Phone Number*
Please enter a valid phone number.
If Patient is a minor, please provide the Parent or Guardian's name:

First NameLast Name
Dental History
Dentist Name*
Check-up Frequency
Does patient need to pre-medicate with antibiotics prior to their dental visit?*

YesNo
Medical History
Physician Name
Patient Health
Has there been any change in the patient's general health within the last year?*

YesNo
Is the patient now under the care of a physician (other than routinely)?*

YesNo
Has the patient had a serious illness/hospitalization in the past 5 years?*

YesNo
List any medications currently being taken by the patient (including no prescriptive ones):
List any drug allergies the patient may have:
Does the patient have any of the following conditions? Check all that apply

Heart MurmurCongenital Heart DefectRheumatic FeverKidney DiseaseHemophiliaProlonged Bleeding/TransfusionHIV/AIDSHandicaps/DisabilitiesDiabetesTuberculosis or Lung DiseaseCancerReceived Chemotherapy or Radiation TreatmentHormone TherapyNervous DisordersSeizures / Epilepsy / Neurological DiseaseAsthmaTake Bisphosphonates (Fosamax, Boniva)Damaged or Artificial Heart ValvesHeart DiseaseLiver Disease / Jaundice / HepatitisHeart Attack/StrokeHypertension/High Blood PressureAnemia / Blood DisorderTonsils/Adenoids RemovedArthritis / Joint ProblemsGrowth ProblemsPneumoniaFamily History of CancerThyroid / Endocrine ProblemsMetal AllergyBone Disorders/Bone LossTreated for Emotional ProblemsSexually Transmitted Disease
If any of the conditions above were selected, please explain:
Should be Empty:

UPDATE Health History

Dental History

Medical History