UPDATE Health History
(EXISTING PATIENTS ONLY)
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Type
*
Please Select
Home
Cell
Work
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
If Patient is a minor, please provide the Parent or Guardian's name:
First Name
Last Name
Dental History
Dentist Name
*
Check-up Frequency
Please Select
Once per Year
Twice per Year
More Than Twice per Year
Never
Emergencies Only
Does patient need to pre-medicate with antibiotics prior to their dental visit?
*
Yes
No
Medical History
Physician Name
Patient Health
Please Select
Good
Excellent
Fair
Poor
Has there been any change in the patient's general health within the last year?
*
Yes
No
Is the patient now under the care of a physician (other than routinely)?
*
Yes
No
Has the patient had a serious illness/hospitalization in the past 5 years?
*
Yes
No
List any medications currently being taken by the patient (including over-the-counter):
List any drug allergies the patient may have:
Does the patient have any of the following conditions? Check all that apply
Heart Murmur
Congenital Heart Defect
Rheumatic Fever
Kidney Disease
Hemophilia
Prolonged Bleeding/Transfusion
HIV/AIDS
Handicaps/Disabilities
Diabetes
Tuberculosis or Lung Disease
Cancer
Received Chemotherapy or Radiation Treatment
Hormone Therapy
Nervous Disorders
Seizures / Epilepsy / Neurological Disease
Asthma
Take Bisphosphonates (Fosamax, Boniva)
Damaged or Artificial Heart Valves
Heart Disease
Liver Disease / Jaundice / Hepatitis
Heart Attack/Stroke
Hypertension/High Blood Pressure
Anemia / Blood Disorder
Tonsils/Adenoids Removed
Arthritis / Joint Problems
Growth Problems
Pneumonia
Family History of Cancer
Thyroid / Endocrine Problems
Metal Allergy
Bone Disorders/Bone Loss
Treated for Emotional Problems
Sexually Transmitted Disease
If any of the conditions above were selected, please explain:
Submit
Should be Empty: