Medical History Update Form [English]

Full Name

Today's Date

Birthdate

Address

City

State

Zip

Home Phone

Cell Phone

Has your employer or Insurance Changed?

Yes No

Physician

Physician's Phone

Please list your medications and dosages

Add Medications

Do you need to Pre-Medicate with Antibiotics before a dental appointment?

Yes No

Have you had a surgery OR been hospitalized in the last 12 months?

Yes No

Type of Surgery

Date

If Other, Please list

I smoke or use tobacco products

Yes No

Women Patients

Are You Pregnant?

Yes No

Do you use Birth Control Pills?

Yes No

Are you nursing?

Yes No

How many weeks pregnant are you?

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

The health of all our patients and staff is our top priority. If you are in the contagious stage of an illness please postpone your appointment until you are well or have your physician's medical clearance.

Short text

Number

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