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Updated Health History
Full Legal Name
Date of Birth
Your health is important to us. In order to provide excellent care with safety, it is necessary to become acquainted with vital information related to each patient. Thus, it is extremely important that you answer the following questions as accurately as possible. If you have any questions regarding the information requested, please feel free to ask the doctor or a member of the staff for assistance.
Have you had any hospitalizations within the past 2 years?
Yes
No
Have you had any surgeries in the last 2 years?
Yes
No
Have you been diagnosed with any new medical conditions in the last 2 years?
Yes
No
If yes, please list them
Please list any NEW medications or recreational drugs you have taken in the past 2 years.
Are you allergic to Penicillin(s)?
Yes
No
Do you have any other allergies or sensitivites? If yes, please list them
Have you had any accidents involving your teeth?
Yes
No
Do you have a latex allergy?
Yes
No
Have you had any excessive bleeding requiring special treatment?
Yes
No
Have you taken any bisphosphonates or osteoporosis / bone cancer meds. within last 5 years?
Yes
No
List any serious medical condition(s):
Do you smoke?
Yes
No
If you do smoke, how frequently?
Do you have diabetes?
Yes
No
Do you have hypertension (high blood pressure)?
Yes
No
Do you have high cholesterol?
Yes
No
Do you have ADHD?
Yes
No
Is there a possibility that you are pregnant?
Yes
No
If you might be pregnant, about how many months?
Are you nursing?
Yes
No
Are you on the Autism spectrum?
Yes
No
Have you ever tested HIV positive?
Yes
No
Do you snore?
Yes
No
Have you ever been told that you stop breathing when you are sleeping?
Yes
No
Do you suffer from frequent or severe headaches?
Yes
No
Do you suffer from any back or neck pain?
Yes
No
Do you have any other health history or medical conditions we did not ask about?
The above medical history is accurate and current to the best of my knowledge. I understand I need to notify this office whenever there is a change in my health history.
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