www.starcaredental.com - Medical History Update Form

  • Medical History Update Form

  • Are you currently under the care of a physician?*
  • Have you had any serious illnesses, injuries or operations?
  • Do you smoke?*
  • Do you use smokeless tobacco?*
  • Do you have any organ transplants?*
  • Is there any reason to believe that your immune system may be compromised?
  • Have you ever required a blood transfusion or kidney dialysis?*
  • Do you have any body piercings or tattoos?*
  • Women: Are you pregnant?*
  • Does your jaw pop, click or grind when you open?*
  • Are you allergic to any of the following?

  • Do you have, or have you had, any of following?

  • *

  • Dental History

  • May we contact your previous dentist?*
  • Format: (000) 000-0000.
  • Have you ever had or do you now have: (Please check all that apply)
  • Do you have missing teeth?*
  • Do you gag easily?*
  • Have you ever had any serious trouble associated with previous dental treatment?*
  • Have you ever had a bad experience in a dental office?*
  • Date*
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  • Should be Empty: