Medical History Update adentaloffice.com

Medical History Update - A Dental Office

Today's Date

Patient Name & Contact Information

First Name

Middle Name

Last Name

Date of Birth

Gender

Family Status

Address

Address Line 1

City

Province

Postal Code

Home Phone

Work Phone

Cell Phone

Work Phone Extension

Are there any changes to your Health History?

Yes

Please Provide More Information:

Are you being treated for any medical condition at present or within 2 years?

Yes

Please Provide More Information:

Have you been hospitalized in last 2 years?

Yes

Please Provide More Information:

Allergies?

Yes

Please Provide More Information:

List all medications currently being taken and reason for use : (including herbal, over the counter supplements)

Signature of patient, parent or guardian

Date