Medical History Update
Reason for today`s visit
Unusual reaction to dental injections?
Are you in pain?
Rheumatic Fever
Tobacco use? If so, what kind and how much?
New patients:
Date of last cleaning and exam
Signature will be recorded later.
Date: 4/26/2024
Do you have BiteWing x-rays that are less than 1 year old?
Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?
City/State
Name of former dentist
Joint Replacement
N
Y
Are you allergic to any of the following?
Anesthetic
N
Y
Iodine
Penicillin
Codeine
Latex
Aspirin
Phone
Emergency Contact
Relationship
First Name:
Last Name:
Medical History Update
City/State:
Name of Medical Doctor:
Birthdate:
Mark any medications that you are no longer taking and add any new ones:
Heart Murmur
Sinus Trouble
Psychiatric Treatment
Diabetes
Ulcers
High Blood Pressure
Stroke
Heart Trouble
Y
Do you have any of the following medical conditions?
N
Y
N
Ibuprofen
Sulfa
Asthma
Pregnancy
Cancer
Liver Disease
Kidney Disease
Bleeding Problems