UPDATED HEALTH HISTORY

Name: ______________________. Date of last dental visit: ______________________.

Have you ever had any of the following? Please check those that apply:

DRUG ALLERGIES: ____________________________________________________________________________________.SURGERIES WITH DATES: ____________________________________________________________________________________

PLEASE LIST ALL MEDICATIONS: ________________________________________________________________________________________________________________________________________________________________________

Do you pre-medicate for dental treatment?

Yes

Have you ever had any complications following dental treatment?

Yes

Have you been admitted to a hospital or needed emergency care in the past two years?

Yes

If yes, please elaborate:

Are you currently under the care of a physician?

Yes

Physician: ___________________________________________. Phone: ________________________

Preferred Pharmacy: ____________________________. Phone: _______________________________

Your information will be encrypted.