Adult Health History Update

To assist us in serving you, please complete the following confidential health questionnaire update form. The information provided is important to your dental health.

Patient's Name

Patient Birthdate

Social Security #

Patient's Home Address

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Employer's Name

Employer's Phone Number

Spouse's Name

Spouse's Cell Phone Number

Physician's Name

Physician's Phone Number

Medical History

Has there been any change in your health in the last year?

Yes No

If yes, what changes?

Are you being treated for any condition by a physician now?

Yes No

If yes, what is the condition?

Date of your last physical exam:

Add additional medication

Add additional allergies

Have you previously taken antibiotics (premedication) for dental appointments?

Yes No

Have you experienced a bad reaction to dental anesthetic?

Yes No

Have you had a major operation or been hospitalized in the last two years?

Yes No

If yes, please explain:

Have you had surgery or x-ray treatment for a tumor, growth, or other condition in your mouth or lips in the last two years?

Yes No

If yes, please explain:

If other, please explain:

Do you smoke or use tobacco products?

Yes No

Which products?

How much?

How long?

For women:

May be Pregnant

Nursing

Taking Birth Control

Expected Delivery Date

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

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