Medical History Update Form

Medical History Update Form
Full Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What is your Gender? *

Male Female
Are you currently under the care of a physician? *

Yes No
If yes, please provide us with the name of physician and phone number
Have you had any recent hospitalizations? *

Yes No
If yes, please explain
Have you had any surgeries? *

Yes No
If yes, please explain
Are you currently taking any medication? *

Yes No
If yes, please list the name of each medication you are taking and the dose prescribed
Do you have any allergies? *

Yes No Not Sure
If yes, please list your allergies and symptoms that occur
Do you use or do you have history of using tobacco? *
For female patients: Is there a chance you could be pregnant?
Do you have any DENTAL issues? *
Has there been any change to your dental insurance? *

Yes No
If yes, please list the new name of your insurance plan
Please include subscriber ID number, group #, and employer
Is there anything else that has changed that you’d like to notify our staff of?
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: