Medical History Update adentaloffice.com

Medical History Update - A Dental Office

Date

Patient Name & Contact Information

Patient Name (First)

Patient Name (Middle)

Patient Name (Last)

Address

Address Line 1

City

Province

Postal Code

Home Phone

Work Phone

Cell Phone

Work Phone Extension

Date of Birth

Gender

Family Status

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:

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

Allergies?

Yes

Please Provide More Information:

Signature of patient, parent or guardian (Print your name*)

Date