Serenity Family Dental of Burlington

Existing Patient Update Form
Email Address
Date
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential, subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire, and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
PATIENT INFORMATION
Name*

First NameMiddle initialLast Name
If you are completing this form for another person, what is your relationship to that person?
Your Name
Relationship
Home Phone
Cell Phone
MEDICAL INFORMATION
Are you currently under the care of a physician?

YesNo
Physician Name
Phone Number
Address / City / State / Zip
Are you in good health?

YesNo
Has there been any change in your general health within the past year?

YesNo
If yes, what condition is being treated?
Date of last physical exam
Do you have a history of chemical dependency?

YesNo
Are you in recovery?

YesNo
If yes, how long have you been in recovery?
Do you use controlled substances (drugs)?

YesNo
Do you use tobacco (smoking, snuff, chew, bidis)?

YesNo
If so, how interested are you in stopping?

VerySomewhatNot Interested
Do you drink alcoholic beverages?

YesNo
If yes, how much alcohol did you drink in the last 24 hours?
Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?

YesNo
If you had an orthopedic total joint (hip, knee, elbow, finger) replacement?, date
If you had an orthopedic total joint (hip, knee, elbow, finger) replacement?, have you had any complications?
Have you had a serious illness, operation or been hospitalized in the past 5 years?

YesNo
If yes, what was the illness or problem?
Do you take any blood thinners?

YesNo
Do you take aspirin on a regular basis?

YesNo
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget's disease?

YesNo
Are you taking or have you recently taken any prescription or over the counter medicine(s)?

YesNo
If you are taking or had recently taken any prescription or over the counter medicine(s), please list all medications, including vitamins, natural or herbal preparations and/or diet supplements
Pregnant?

YesNo
Number of weeks
Taking birth control pills or hormonal replacements?

YesNo
Nursing?

YesNo
ALLERGIES Please mark "Yes" if you are allergic to (or have had a reaction to) the following.
Local anesthetics

YesNo
Aspirin

YesNo
Penicillin or other antibiotics

YesNo
Barbiturates, sedatives, or sleeping pills

YesNo
Sulfa drugs

YesNo
Codeine or other narcotics

YesNo
Metals

YesNo
Latex (rubber)

YesNo
Iodine

YesNo
Hay fever / seasonal

YesNo
Animals

YesNo
Food / Other

YesNo
If yes, please specify
Please mark "Yes" if you have (or have had) any of the following diseases or problems.
Heart murmur

YesNo
Mitral valve prolapse

YesNo
Artificial heart valves

YesNo
Rheumatic fever

YesNo
Cardiovascular disease

YesNo
Angina

YesNo
Arteriosclerosis

YesNo
Congestive heart failure

YesNo
Coronary artery disease

YesNo
Damaged heart valves

YesNo
Heart attack

YesNo
Low blood pressure

YesNo
High blood pressure

YesNo
Congenital heart defects

YesNo
Pacemaker

YesNo
Pacemaker

YesNo
Rheumatic heart disease

YesNo
Abnormal bleeding

YesNo
Anemia

YesNo
Blood transfusion

YesNo
If yes on Blood transfusion, date
Hemophilia

YesNo
AIDS or HIV infection

YesNo
Arthritis

YesNo
Autoimmune disease

YesNo
Rheumatoid arthritis

YesNo
Systematic lupus erythematosus

YesNo
Asthma

YesNo
Bronchitis

YesNo
Emphysema

YesNo
Sinus trouble

YesNo
Tuberculosis

YesNo
Cancer / Chemotherapy / Radiation treatment

YesNo
Chest pain upon exertion

YesNo
Chronic pain

YesNo
Diabetes type I or type II

YesNo
Eating disorder

YesNo
Malnutrition

YesNo
Gastrointestinal disease

YesNo
GE Reflux / persistent heartburn

YesNo
Ulcers

YesNo
Thyroid problems

YesNo
Stroke

YesNo
Glaucoma

YesNo
Hepatitis, jaundice, or liver disease

YesNo
Epilepsy

YesNo
Fainting spells or seizures

YesNo
Neurological disorders

YesNo
If yes on Neurological disorders, please specify
Gag Reflex Sensitivity

YesNo
Sleep disorder

YesNo
Mental health disorders

YesNo
If yes on Mental health disorders, please specify
Recurrent infections

YesNo
If yes on Recurrent infections, please specify
Kidney problems

YesNo
Night sweats

YesNo
Osteoporosis

YesNo
Persistent swollen glands in neck

YesNo
Severe headaches / migraines

YesNo
Severe / rapid weight loss

YesNo
STDs / STIs

YesNo
Excessive urination

YesNo
ADD

YesNo
ADHD

YesNo
Sensory Processing Disorder

YesNo
Oral Sensory Sensitivity

YesNo
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

YesNo
Do you have any disease, condition, or problem not listed above that you think we should know about?

YesNo
If you have any disease, condition, or problem not listed above that you think we should know about, please explain
PHARMACY INFORMATION
Pharmacy Name
Pharmacy Phone
Pharmacy Address
SIGNATURE
NOTE: Both the Doctor and the patient are encouraged to discuss any relevant patient health issues before treatment.
Name of Patient/Legal Guardian
Date
Signature of Patient/Legal Guardian

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Cancelof
***
Should be Empty:

Existing Patient Update Form

PATIENT INFORMATION

If you are completing this form for another person, what is your relationship to that person?

MEDICAL INFORMATION

ALLERGIES Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

PHARMACY INFORMATION

SIGNATURE