Established Patient - Dental Medical and History Update

To ensure the highest quality of healthcare, we ask that you complete this patient update form. Note: If you have not been seen in our office for over a year, we will require an update on your Health History.
 

Any changes in Dental Insurance?
 Yes
 No

Current Dentist
Has there been any changes in your health since your last appointment? If yes, please explain.
Have you had any Major Health Issues, Surgeries or Hospitalizations since your last appointment? If yes, please explain.
Has there been any change in your dental health since your last appointment? If yes, please explain.
NEW family history of cancer or other health issues since your last visit? If yes, please explain.
Are you taking any kind of medications &/or supplements - prescription &/or non-prescription? If yes, please explain.
Have you ever taken bisphosphantes, antiresporptive, or antiangiogenic drugs (medicine that effects bone growth or metabolism)? If yes, please explain.
Are you Allergic to any medications, foods, dental anesthetics or latex?
Do you use any tobacco products?
(Female) Are you pregnant?Please Choose OneYesNo
(Female) Are you taking birth control?Please Choose OneYesNo