Update Health History Form

Date:

Patient Name:

DOB:

Contact information

Email:

Phone #:

Preferred method of contact: Phone Email

Any address change? Yes No

New address:

City:

Zip Code:

Any changes with dental insurance? Yes No

If yes:

Primary care physician

Name:

Phone #:

Dentist

Name:

Phone #:

Any change with your health since your last visit with us? Yes No

If yes:

Any surgeries or hospitalizations since your last visit with us? Yes No

If yes:

Date of surgery/hospitalization:

Any change in dental health since your last visit with us? Yes No

If yes:

Any new family history of cancer or other issues? Yes No

If yes:

Are you currently taking any medications or supplements (prescription and/or non-prescription) ? Yes No

If yes list medications:

Are you allergic to any medications, foods, or latex? Yes No

If yes:

Do you use any tobacco products? Yes No

If yes:

Females only: Are you pregnant? Yes No

Females only: Are you taking birth control? Yes No

I Certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries above have been answered to my satisfaction. I will not hold my doctor, or any other member of his/her staff, responsible for any errors or omissions that I have made in my completion of this form.

Patient Signature

Date

Established Patient- Dental/Medical History Update

Contact information

Primary care physician

Dentist