Health History Update

For existing patients of Dental Clinic to update medical conditions, medications, or surgical history since their last visit.

1. Patient Identification

Full Name *

Date of Birth *

Phone Number *

Email Address *

2. Primary Care Physician

Physician Name

Physician Office Phone

3. Recent Health Changes & Surgeries

Any changes in your general health in the past year?

NoYes

Any hospitalizations, serious illnesses, or surgeries?

NoYes

4. Medications & Allergies

Any new prescription or OTC medications/vitamins?

NoYes

Any new allergies (drugs, latex, metals, food)?

NoYes

List current medications, dosage, and known allergies:

6. Patient Verification & Signature

I certify that I have read and understand the questions above, and have accurately answered all information regarding my medical history to the best of my knowledge.

Patient Signature*

Sign here using mouse or finger

Date *

256-bit Encrypted & HIPAA Compliant Transmission

Health History Update Form