clearcareperio.com - Medical History Update Form

Medical History Update Form
Patient’s Name*

First NameLast Name
IN CASE OF EMERGENCY
Emergency Contact Name*
Relationship*
Email*
example@example.com
Cell Phone Number *
Please enter a valid phone number.
MEDICAL HISTORY

Please Check “Yes” or “No” to indicate if you have had any of the following
Are you currently taking any medications?*

YesNo
If yes, what type?*
Do you require premedication before dental treatment?*

YesNo
Are you sensitive or allergic to any medication?*

YesNo
If yes, what type?*
HIV/AIDS*

YesNo
Cancer/Chemotherapy*

YesNo
Asthma*

YesNo
Tuberculosis*

YesNo
Rheumatic Fever*

YesNo
Scarlett Fever*

YesNo
Heart Murmur*

YesNo
Thyroid Disease*

YesNo
Hepatitis*

YesNo
Diabetes*

YesNo
Epilepsy or Seizures*

YesNo
Pacemaker*

YesNo
Psychiatric treatment*

YesNo
High Blood Pressure*

YesNo
Low Blood Pressure*

YesNo
Stroke*

YesNo
Anemia*

YesNo
Ulcers*

YesNo
Arthritis*

YesNo
Cold Sores (Herpes)*

YesNo
Kidney Disease*

YesNo
Bladder Disease*

YesNo
Nervousness*

YesNo
Fainting or Dizzy Spells*

YesNo
Do you have pain in the chest upon exertion?*

YesNo
Do you have shortness of breath?*

YesNo
Do you bruise easily?*

YesNo
Have you ever had Yellow Jaundice?*

YesNo
Are you thirsty much of the time?*

YesNo
Have you lost or gained weight (more than 10 pounds) in the last year?*

YesNo
Are you following a diet?*

YesNo
Has a doctor ever said you have cancer or a tumor?*

YesNo
Have you ever had excessive bleeding from a cut or wound?*

YesNo
Do you have frequent severe headaches?*

YesNo
Do you sometimes take medicine to relieve nervousness?*

YesNo
Are you taking birth control pills?*

YesNo
Are you pregnant?*

YesNo
Are you a smoker?*

YesNo
How often do you smoke?*
What is your approximate weight?*
What is your approximate height?*
Do you have any disease, condition, or problem not listed above?*

YesNo
If yes, please explain*
Signature of patient or guardian*

Clear
Printed name of patient or guardian*

First NameLast Name
Date*

MonthDayYear
Date
TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE ANSWERS ARE TRUE AND CORRECT. IF I HAVE ANY CHANGE IN MY CONTACT INFORMATION, CHANGE OF ADDRESS, CHANGE OF INSURANCE OR CHANGE IN HEALTH, I WILL INFORM CLEARCARE PERIODONTAL & IMPLANT CENTRE AT MY NEXT APPOINTMENT.
Should be Empty:

Medical History Update Form

IN CASE OF EMERGENCY

MEDICAL HISTORY