Updated Health History
Name
First Name
Last Name
Home Phone:
-
Area Code
Phone Number
Cell Phone:
-
Area Code
Phone Number
Email:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place of Employment:
Work Phone:
-
Area Code
Phone Number
Name of Dental Insurance Co:
How would you like appointment confirmation?
E-mail
Text
Phone Call
Has there been any change in your health since your last visit?
Yes
No
If yes, please explain
Are you allergic to any medication?
Yes
No
If yes, Please list
Are you taking any medication?
Yes
No
If yes, Please list
Are you pregnant, breast feeding or trying to get pregnant?
Yes
No
Have you had a heart valve or joint replacement surgery?
Yes
No
If yes, have you taken your antibiotics today?
Yes
No
Are you having specific dental problems at this time?
Yes
No
If yes, Please explain
Are you or have you ever taken osteoporosis medication?
Yes
No
If yes, for how long and are you still taking it?
Please circle any condition that apply to you in any way
Heart Attack
Hypoglycemia
Lung Disease
Hemophilia
Sensitive Teeth
Tuberculosis
Unhappy With My Smile
Low Blood Pressure
Tobacco Use
HIV Positive
Stroke
Cold Sores
Bladder or Kidney
High Blood Pressure
Birth Control Pills
Asthma
Hepatitis/Jaundice
ED Medications
Epilepsy/Seizures
Latex Sensitivity
Diabetic
Angina
Snoring
Other
Type a question
Signature
Clear
-
Month
-
Day
Year
Date
For Office Use Only
Reviewed By:
Blood Pressure
Temperature
Submit
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