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Health History Update
Completed once per year
* Indicates required question
Today's Date
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MM
/
DD
/
YYYY
Patient Name
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Your answer
Address
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Your answer
Phone #
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Your answer
Email
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Your answer
Pharmacy
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Your answer
Any change in dental health since last visit?
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Yes
No
Any changes in medical history since last visit?
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Yes
No
Any surgeries or hospitalizations since last dental visit?
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Yes
No
If you answered yes to recent hospitalization, then please describe situation.
Your answer
Do you have any heart conditions?
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Yes
No
Are you taking any prescription medications?
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Yes
No
If you answered yes above. What prescriptions are you taking?
Your answer
Are you taking bisphosphonates, antiresorptive, or antiangiogenic drugs (medicines that affect bone growth or metabolism)?
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Yes
No
Do you currently take an antibiotic premedication prior to your dental appointment?
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Yes
No
Are you allergic to any medications, foods, or latex?
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Yes
No
If you answered yes to allergies then please specify below
Your answer
Do you use any tobacco products?
Yes
No
Clear selection
Female Patients: Are you pregnant?
Yes
No
Clear selection
Female Patients: Are you breastfeeding?
Yes
No
Clear selection
I certify that I have read, and 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 the completion of this form.
Enter your full name below.
*
Your answer
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