Medical Information Update

Prefix

Patient First and Last Name

Other (Nickname, etc)

Gender

Male

Female

Is patient a minor?

No

Yes

Birthdate

/

Age

Name of family dentist

Did he/she refer you to our office?

No

Yes

Street

City

State

Zip

Home Phone

Cell Phone

Email

Dental Insurance Company

Dental Insurance policy holder

Parent/Guardian #1

Prefix

First and Last Name

Birthdate

/

Relationship to Patient

Marital Status

Street

City

State

Zip

Home Phone

Cell Phone

Email

Dental Insurance Company

Dental Insurance Policy Holder

Add 2nd Parent/Guardian

No

Yes

Parent/Guardian #2

Prefix

First and Last Name

Birthdate

/

Relationship to Patient

Marital Status

Street

City

State

Zip

Home Phone

Cell Phone

Email

Dental Insurance Company

Dental Insurance Policy Holder

Medical Details

Does the patient have or has he/she ever had:

Asthma or Breathing Problem

No

Yes

Heart Disease

No

Yes

Sinus Trouble/Hay Fever

No

Yes

Autoimmune Disorder

No

Yes

Hepatitis or Liver Problems

No

Yes

Tuberculosis or Lung Disease

No

Yes

Congenital Heart Defect

No

Yes

Osteoporosis

No

Yes

Other Diagnosis

Does the patient have or has he/she ever had Allergies to:

Latex

No

Yes

Local Anesthetic

No

Yes

Allergy to Other Medication

No

Yes

(Other Medication Allergies)

Other Allergies

No

Yes

(Allergies Other)

List Current Medications

Pregnant (if yes, due date)?

No

Yes

Due Date

/

By signing below, I certify that the information I have provided today is complete and accurate. I also understand that it is my responsibility to inform the office of any changes regarding my (or my child's) medical health.

Signature of Patient (Parent or Guardian if Minor)

Date

/