Dental Medical History Update
Patient Information
Full Name
Date of Birth
Phone
Email
Today's Date
Medical History
Are you under a physician’s care?
Yes
No
If yes, please explain
Have you had any hospitalizations or surgeries?
Yes
No
If yes, please explain
List current medications
Allergies
Do you use tobacco products?
Yes
No
Women: Are you pregnant?
Yes
No
If yes, how many months?
Check any of the following that you have had or currently have:
Diabetes
High Blood Pressure
Heart Disease
Asthma
Epilepsy/Seizures
Cancer
Hepatitis
Thyroid Disorder
Other
If other, please specify
Dental History Update
Date of Last Dental Visit
Any changes in dental health?
Are you experiencing any dental problems now?
Yes
No
If yes, please explain
Signature & Verification
Signature
Date