Medical Update Form
Required fields
Patient First and Last Name
Birth Date
Gender at birth
Male
Female
With what gender do you identify?
Age
The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.
Is, Has or Does the patient...
allergic to latex?
Yes
No
take antibiotic premedication prior to any dental procedures?
Yes
No
If yes, please list medication type and dosage:
in general good health at this time?
Yes
No
If no, please specify:
had any adverse response to any drugs, including penicillin?
Yes
No
If yes, please specify:
allergic to any known materials resulting in hives, asthma, eczema, etc.?
Yes
No
If yes, please specify:
List all medications/supplements you are currently taking and dosages.
ever had any major operations including hip/joint replacement?
Yes
No
If yes, please specify:
have any wounds healed slowly or presented other complications?
Yes
No
If yes, please specify:
ever had any radiation therapy or chemotherapy?
Yes
No
If yes, please specify:
ever had a serious accident involving facial and/or head injuries?
Yes
No
If yes, please describe:
Does the patient have or has he/she ever had:
AIDS OR HIV POSITIVE
Yes
no
DIZZINESS
Yes
No
HERPES
Yes
No
ALCOHOLISM
Yes
no
DRUG ABUSE
Yes
No
IMMUNE SYSTEM PROBLEMS
Yes
No
ARTHRITIS OR PAINFUL JOINTS
Yes
no
EMOTIONAL PROBLEMS
Yes
No
INFECTIOUS DISEASE
Yes
No
ASTHMA
Yes
no
EPILEPSY
Yes
No
MIGRAINE HEADACHES
Yes
No
BLOOD DISEASE
Yes
no
EXCESSIVE BLEEDING
Yes
No
RESPIRATORY PROBLEMS
Yes
No
BONE DISORDER
Yes
no
FAINTING
Yes
No
RHEUMATIC FEVER
Yes
No
CANCER
Yes
no
HAY FEVER
Yes
No
SEXUALLY TRANSMITTED DISEASE
Yes
No
CARDIOVASCULAR DISEASE
Yes
no
HEARING DISORDER
Yes
No
SINUS PROBLEMS
Yes
No
CONVULSIONS
Yes
no
HEART MURMUR
Yes
No
TONSILLITIS
Yes
No
DIABETES
Yes
no
HEPATITIS OR LIVER DISEASE
Yes
No
TUMOR OR GROWTH
Yes
No
Other
Yes
No
Other pertinent conditions not listed:
Does the patient snore?
Yes
No
Does the patient have unexplained awakenings from sleep?
Yes
No
Does the patient, or has the patient been told that you stop breathing for short periods during sleep?
Yes
No
Does the patient get excessively tired during the day and/or fall asleep when you should be awake?
Yes
No
Is the patient on a diet at this time?
Yes
No
Is the patient pregnant?
Yes
No
Has the patient ever smoked or used tobacco products?
Yes
No
If so, how long ago?
By signing below, I certify that the information I have provided today is complete and accurate. I also understand that it is my responsibility to inform the office of any changes regarding my (or my child's) medical health.
Signature of Patient (Parent or Guardian if minor)
Date
Submit
Do not close this window until you receive a message that your form has been submitted.
