Patient Update Form - Health History - Consent
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1
2Patient Information Update
Patient Information Update
Date:_______________
Date:_______________
Mr./ Mrs./ Ms./ Miss/ Dr. _________________________________________________________________________
first
middle
last
Date of birth: ____________ Sex: ____ SS #: ____________________Marital Status: Married Divorced Single
Home Address: _________________________________ City: __________________ State:_____ Zip:________
Home Phone: ____________ Cell: ____________ Work: ____________E-mail:____________________________
Would you like to receive appointment confirmation through:
email
text
neither
Emergency Contact: _____________________Tele #______________________ Relation:____________________
Primary Dental Insurance: ______________ ___________________ Group#:_______________________________
Identification#:__________________________ Subscriber’s Name: ______________________________________
Employer:________________________________________ Date of birth: ________ SS #: ___________________
Secondary Dental Insurance: _________________________________ Group#:_____________________________
please present your dental insurance card for duplication.
If new insurance,
Health History
Name of your medical doctor: ________________________________ Date of last visit to medical doctor: ________
Have you taken any medicine or drugs during the past 2 years? Yes _____ No _____
Are you now taking any medication, drugs, or pills? Yes _____ No _____
If yes, please list: _______________________________________________________________
Are you allergic or have reacted adversely to any of the following medications:
Aspirin
Erythromycin
Penicillin
Sleeping Pills
Darvon
Tetracycline
Other Antibiotics
(Nembutal/
Codeine
Percodan
Local Anesthetic
Seconal)
Demerol
Valium
(Novocain or
Sulfa
Nitrous Oxide
Scopolamine
Xylocaine)
Are you aware of being allergic to any other medications or substance? Yes_____ No _____
If yes, please list: _______________________________________________________________
Circle any of the following which you have had or have at present:
Heart Failure
Cough
Hepatitis A (infectious)
Heart Disease or Attack
Tuberculosis (TB)
Hepatitis B (serum)
Angina Pectoris
Asthma
Liver Disease
High Blood Pressure
Hay Fever
Yellow Jaundice
Heart Murmur
Sinus Trouble
Blood Transfusion
Rheumatic Fever
Allergies or Hives
Drug Addiction
Congenital Heart Lesions
Diabetes
Hemophilia
Scarlet Fever
Thyroid Disease
Venereal Disease (Syphilis,
Artificial Heart Valve
X-ray or Cobalt Treatment
Gonorrhea)
Heart Pacemaker
Cancer
Cold Sores
Heart Surgery
Chemotherapy (Cancer, Leukemia)
Fever Blisters
Artificial Joints (Hip, Knee)
Arthritis
Epilepsy or Seizures
Anemia
Rheumatism
Fainting or Dizzy Spells
Stroke
Cortisone Medicine
Nervousness
Kidney Trouble
Glaucoma
Psychiatric Treatment
Ulcers
Pain in Jaw Joints (TMJ)
Sickle Cell Disease
Cosmetic Surgery
A.I.D.S.
Bruise Easily
Emphysema
HIV positive
Do you have any disease, condition, or problem not listed above? Yes_____ No _____
If yes, please list: _______________________________________________________________
Please read and sign the consent on the reverse side.
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Parent category: Medical