• Medical History Update Form

  • IN CASE OF EMERGENCY

  • Format: (000) 000-0000.

  • MEDICAL HISTORY

    Please Check “Yes” or “No” to indicate if you have had any of the following
  • Are you currently taking any medications?*
  • Do you require premedication before dental treatment?*
  • Are you sensitive or allergic to any medication?*
  • HIV/AIDS*
  • Cancer/Chemotherapy*
  • Asthma*
  • Tuberculosis*
  • Rheumatic Fever*
  • Scarlett Fever*
  • Heart Murmur*
  • Thyroid Disease*
  • Hepatitis*
  • Diabetes*
  • Epilepsy or Seizures*
  • Pacemaker*
  • Psychiatric treatment*
  • High Blood Pressure*
  • Low Blood Pressure*
  • Stroke*
  • Anemia*
  • Ulcers*
  • Arthritis*
  • Cold Sores (Herpes)*
  • Kidney Disease*
  • Bladder Disease*
  • Nervousness*
  • Fainting or Dizzy Spells*
  • Do you have pain in the chest upon exertion?*
  • Do you have shortness of breath?*
  • Do you bruise easily?*
  • Have you ever had Yellow Jaundice?*
  • Are you thirsty much of the time?*
  • Have you lost or gained weight (more than 10 pounds) in the last year?*
  • Are you following a diet?*
  • Has a doctor ever said you have cancer or a tumor?*
  • Have you ever had excessive bleeding from a cut or wound?*
  • Do you have frequent severe headaches?*
  • Do you sometimes take medicine to relieve nervousness?*
  • Are you taking birth control pills?*
  • Are you pregnant?*
  • Are you a smoker?*
  • Do you have any disease, condition, or problem not listed above?*
  • 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: