Medical Update Form

Patient Name:

Have you been under the care of a medical doctor during the past two years?

Yes No

If yes, for what?

Physician's Name:

Phone:

Address:

City:

State:

Zip:

Have you taken any medication or drugs during the past two years?

Yes No

Are you taking any medication, drugs or pills now?

Yes No

If yes, please list name and dosage:

Add medication/drugs/pills

Are you aware of having an allergic (or adverse reaction) to any medication or substance?

Yes No

If yes, please list:

Add medication/substance

Have you been a patient in the hospital during the past 5 years?

Yes No

Indicate which of the following you have had, or have at present. Circle "yes" or "no" to each of them.

Heart (Surgery, Disease, Attack)

Yes No

Ulcers

Yes No

Implants/Cosmetic Surgery

Yes No

Chest Pain

Yes No

Diabetes

Yes No

Hepatitis (A,B,C)

Yes No

Congenital Heart Disease

Yes No

Thyroid Problems

Yes No

A.I.D.S

Yes No

Heart Murmur

Yes No

Glaucoma

Yes No

H.I.V Positive

Yes No

High Blood Pressure

Yes No

Contact Lenses

Yes No

Cold Sores/Fever Blisters

Yes No

Mitral Valve Prolapse

Yes No

Emphysema

Yes No

Blood Transfusion

Yes No

Artificial Heart Valve

Yes No

Chronic Cough

Yes No

Hemophilia/Sickle Cell Disease

Yes No

Heart Pacemaker

Yes No

Tuberculosis

Yes No

Bruise Easily

Yes No

Rheumatic Fever

Yes No

Asthma

Yes No

Liver Disease/Yellow Jaundice

Yes No

Arthritis/Rheumatism

Yes No

Hay Fever

Yes No

Neurological Disorder

Yes No

Cortisone Medicine

Yes No

Latex Sensitive

Yes No

Epilepsy or Seizures

Yes No

Swollen Ankles

Yes No

Allergies or Hives

Yes No

Fainting or Dizzy Spells

Yes No

Stroke

Yes No

Sinus Trouble

Yes No

Nervous/Anxious/Stress

Yes No

Diet(Special/Restricted)

Yes No

Radiation Therapy

Yes No

Psychiatric/Psychological Care

Yes No

Artificial Joints (hips, knee, etc.)

Yes No

Chemotherapy

Yes No

Venereal Disease

Yes No

Kidney Trouble

Yes No

Tumors

Yes No

Do you require an antibiotic prior to dental treatment?

Yes No

Do you use more than two pillows to sleep?

Yes No

Do you have or have you had any disease conditions, or problems not listed?

Yes No

If yes, please list:

Add disease condition or problem

Women:

Are you pregnant?

Yes No

If yes, how many months:

Nursing?

Yes No

Taking birth control pills?

Yes No

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency who may release such information to you. I will notify the doctor of any change in my health or medication.

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:

Dr. Signature:

Date:

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