Medical History Update
Medical History Update
Pregnancy
Diabetes
Psychiatric Treatment
Heart Murmur
Sinus Trouble
Cancer
Asthma
Kidney Disease
Bleeding Problems
Liver Disease
N
Reason for today`s visit
Are you in pain?
New patients:
Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?
Unusual reaction to dental injections?
Name of former dentist
City/State
Date of last cleaning and exam
Do you have BiteWing x-rays that are less than 1 year old?
Heart Trouble
Tobacco use? If so, what kind and how much?
Stroke
High Blood Pressure
Ulcers
Joint Replacement
Rheumatic Fever
Date: 5/16/2024
Y
Y
Last Name:
First Name:
Birthdate:
Name of Medical Doctor:
City/State:
Phone
Relationship
Please provide any medications that you are currently taking:
Emergency Contact
N
Latex
Codeine
Ibuprofen
Sulfa
Do you have any of the following medical conditions?
Penicillin
Are you allergic to any of the following?
Y
N
Y
N
Aspirin
Anesthetic
Iodine
List Others:
Name/Signature:
List Others: