HEALTH HISTORY UPDATE
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| Name | |
| Date | |
| Do you have any current health problems? | |
| If yes, please describe | |
| Are you currently under the care of a physician? | |
Please list your physician with name and town of
clinic | |
What medications are you taking and for what
reasons? (including birth control) Write none if
so. | |
Please list any medications you are allergic to or
type none if you aren't aware of any. | |
| Have you ever taken blood thinners? | |
Have you ever taken a bisphosphonate (such as
Fosamax. Boniva, Actonel, Zometa, etc) | |
| Are you pregnant? | |
Have you ever taken an antibiotic prior to dental
appointments? (Premed) | |
| Are you allergic to latex? | |
| Do you use tobacco? | |
Check any of the following conditions that you
have or have previously had. | Prosthetic (knee, hip, etc) Heart disease or attack Diabetes Stroke Hepatitis AIDS or HIV positive Cancer / chemotherapy High Blood Pressure Pacemaker Kidney problems Liver disease Tuberculosis (TB) Heart valve replacement Mitral valve prolapse Endocarditis Drug or alcohol addiction Eating disorder Asthma Acid reflux Sinus problems Other |
Please describe conditions checked (dates, etc)
and list any other conditions not listed above | |
Additional information about your health the you
feel we should be aware of | |
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Electronic Signature* | By typing your full name, you (or guardian ifunder 18) are providing your electronic signaturestating the information on this form is completeand accurate to the best of your knowledge. |
| Image Verification |  | |
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