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?
*
Please Select
Yes
No
For female patients: Is there a chance you could be pregnant?
Yes
No
Unsure
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
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: