Medical Update Form

Mr. Mrs. Ms. Dr.

Patient First Name

Middle Initial

Patient Last Name

Gender

Male Female

Date of Birth

Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Extension

Insurance Information

Has there been any change to your insurance coverage since your last visit?

Yes No

Primary Dental Insurance Company

Insured's Name

Relationship to Patient

SSN

Date of Birth

Insured’s Employer

Employer Address

City

State

Zip Code

Insurance Co. Name

Address

City

State

Zip Code

Telephone

Plan Name

Group #

Policy ID

Do you have secondary dental insurance?

Yes No

Secondary Dental Insurance Company

Insured's Name

Relationship to Patient

SSN

Date of Birth

Insured’s Employer

Employer Address

City

State

Zip Code

Insurance Co. Name

Address

City

State

Zip Code

Telephone

Plan Name

Group #

Policy ID

Dental History

Why have you come to the dentist today?

Are you currently in pain?

Yes No

Do you require antibiotics before dental treatment?

Yes No

Your current dental health is

Good Fair Poor

Do you floss daily?

Yes No

Do you brush daily?

Yes No

Type of bristles on your toothbrush?

Hard Medium Soft

Do your gums ever bleed?

Yes No

Do your gums ever itch?

Yes No

Have you ever had periodontal disease?

Yes No

Are your teeth sensitive to heat, cold, or anything else?

Yes No

Please explain

Do you have mobility in your teeth?

Yes No

Do you still have your wisdom teeth?

Yes No

Would you like fresher breath?

Yes No

Would you like whiter teeth?

Yes No

Are you happy with the way your smile looks?

Yes No

If not, what would you change?

Medical History

Your current physical health is:

Good Fair Poor

Are you currently under the care of a physician?

Yes No

Please explain:

Has your medical doctor informed you of the need to be pre-medicated before dental treatment?

Yes No

Do you smoke or use tobacco in any other form?

Yes No

Are you taking Coumadin or any blood thinner?

Yes No

Have you ever taken Fosamax or any other bisphosphonate?

Yes No

Have you had or do you currently have the following:

Atrial Fibrillation

Yes No

Alcohol Abuse

Yes No

Anemia

Yes No

Arthritis

Yes No

Artificial Joints

Yes No

Artificial Valves

Yes No

Asthma

Yes No

Blood Disease

Yes No

Blood Transfusion

Yes No

Cancer

Yes No

Celiac

Yes No

Chemo or Radiation

Yes No

Congenital Heart Defect

Yes No

Depression

Yes No

Diabetes

Yes No

Dizziness

Yes No

Drug Abuse

Yes No

Epilepsy or Seizure

Yes No

Excessive Bleeding

Yes No

Fainting

Yes No

Fever Blisters

Yes No

Glaucoma

Yes No

Head Injuries

Yes No

Headaches

Yes No

Heart Attack

Yes No

Heart Disease

Yes No

Heart Murmur

Yes No

Heart Surgery

Yes No

Hemophilia

Yes No

Hepatitis

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

Hip Replacement

Yes No

HIV or AIDS

Yes No

Jaundice

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Lupus

Yes No

Mental Disorders

Yes No

Mitral Valve Prolapse

Yes No

Nervous Disorders

Yes No

Osteoporosis

Yes No

Pacemaker

Yes No

Persistent Coughing

Yes No

Psychiatric Problems

Yes No

Respiratory Problems

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Scarlet Fever

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus Problems

Yes No

Stomach Problems

Yes No

Stroke

Yes No

Thyroid

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumors

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Is there any disease, condition, or problem that you think our office should know about that is not listed above?

Yes No

If yes, please list below

Medications

Please list all medications, over the counter and herbal supplements, that you are currently taking
(include medication name, dosage and frequency):

Allergies/ Reactions

Are you allergic to, or had a reaction to any of the following?

Amoxicillin

Yes No

Latex

Yes No

Aspirin

Yes No

Metals

Yes No

Ceclor

Yes No

Penicillin

Yes No

Clindamycin

Yes No

Sedatives

Yes No

Codeine

Yes No

Sulfa Drugs

Yes No

Dental Anesthetics

Yes No

Tetracycline

Yes No

Erythromycin

Yes No

Please list any allergy/reaction that you have or have had that is not listed above.

For Women Only

Is there a possibility of pregnancy?

Yes No

If yes, number of weeks

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

WARNING: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.

Form Completion

I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary services I may need. I assign the Doctor all insurance benefits. I understand that I am responsible for payment of services rendered, any deductible, and co-payment that my insurance does not cover.

Signature of Patient, Parent or Guardian:

Clear

Clear

Date

If Patient is a Minor

Form signed by:

Relationship to Patient: