Medical History Update (Adult) Form

Medical History Update

What is a food item that you like? [explain]

What is your birth year?

1. Have you been treated by a physician since completing a full medical history here?

Yes No

For what?

Your Physician

Name:

Telephone: ()

Address:

City: , Zip

2. Has there been any change in your health in the last year?

Yes No

Please explain:

3. Are you currently taking any medications?

Yes No

Please explain:

4. Are you allergic to any medications or foods?

Yes No

Please explain:

5. Have you been advised to take antibiotic premedication before certain dental appointments?

Yes No

Did you premedicate one hour before today's appointment?

Yes No

I have answered all questions to the best of my knowledge and understand that the above information is necessary to provide safe dental care. I will notify the doctor and his staff of any changes in my health or medication before proceeding with future treatment.