Medical History UpdatePlease take a moment to update any changes to your personal information below: Client Name * First Name Last Name Title (Mr. Mrs. Ms.) Gender Male Female Family Status Single Married Child Other Birth Date MM DD YYYY Previous Visit MM DD YYYY Email Address Home (###) ### #### Mobile (###) ### #### Work (###) ### #### extension Best time to call: Address Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Dental Insurance Name of Insured (last, first) Client's Relationship to Insured Self Spouse Child Other Insurance Plan Name: Subscriber ID # Group # Insured's Employer Information The following is for: the client the person responsible for payment both not applicable Employer Name Employer Phone: (###) ### #### Employer's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Are you now under the care of a physician? * Yes No If yes, please explain: Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment. Have you had any serious illnesses, or have you been hospitalized in the last 5 years? If yes, please explain. * Indicate which of the following conditions you have or have had. * By checking the box it will indicate a "YES" response, leaving it blank will indicate a "NO" response. PREMED-Other Allergy-Chlorhexidine Allergy-Acrylic Allergy-Aspirin Allergy-Codeine Allergy-Darvocet Allergy-Jewelry Allergy-Latex Allergy-Local Anesth Allergy-Metal Allergy-Other Allergy-Penicillin Allergy-Red Dye Allergy-Sulfa Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis Artificial Heart Valve Artificial Joints Asthma Blood Disease/Disorder Blood Thinners Breathing Problems Bruise Easily Cancer Chemotherapy Cold Sores Congenital Heart Disease Cortizone Medication Diabetes Drug Addiction Emphysema Epilepsy/Seizures Excessive Bleeding Excessive Thirst Fainting/Dizziness Frequent Cough Frequent Headaches Glaucoma Gout Hay Fever Heart Disease Heart Murmur Heart Pacemaker Hemophilia Hepatitis B Hepatitis C High Blood Pressure High Cholesterol HIV/AIDS Hives/Rash HPV Hypoglycemia Intestinal Disease Irregular Heartbeat Kidney Disease Leukemia Liver Disease Malignant Hypertherm Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatment Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Sickle Cell Disease Sinus Problems Sjogren's Stroke Swelling of Limbs Thyroid Disease TMJ Tonsillitis Tuberculosis Tumors None of the Above Recent hospitalization (illness or injury) * yes no Presently being treated for any other illness/conditions? * yes no Have you had a head or neck injury? * yes no Have a cough that produces blood? * yes no Been exposed to anyone with Tuberculosis? * yes no Use tobacco - smoke, vape, or chew? * yes no Have a chemical dependancy? * yes no Have an alcohol dependancy? * yes no Use marijuana medically or recreationally? * yes no Have you had the HPV vaccination? * yes no Do you suffer from Dry Mouth? * yes no Are you on a special diet? * yes no Have you ever been diagnosed with Endocarditis? * yes no Have you ever had Rheumatic Fever? * yes no Have you ever had Mitral Valve Replacement? * yes no If any conditions or alerts selected above need further clarification, please describe below: Women Only: Please select all that apply: Currently Pregnant Currently Nursing Currently Taking Birth Control Trying to get pregnant (Invitro) Hormone Replacement Therapy Are you presently being treated or scheduled to begin treatment using bisphosphonates such as (Fosamax, Boniva, Aredia, Zometa, etc.) for bone density therapy? * yes no If yes, start date: Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? * yes no Do you take antibiotic premedication for your dental visits? * yes no If yes, please explain your need to premedicate: Are you taking or have you recently taken prescription or over the counter medication? * yes no If yes, please list all including vitamins, herbal, natural and/ or dietary supplements. Please list any medications you are currently taking, one medication per line. Have you been tested for Covid-19? (If you have please indicate the date and results.) Have you been in close proximity to anyone known to have tested positive for Covid-19? Physician Name and Phone Number: Previous dentist name and phone number: Pharmacy Name and Phone Number * By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes. This will serve as my electronic signature. * This will serve as my electronic signature. Thank you!
