Health History Update
Completed once per year
Today's Date *
Patient Name
Address *
Phone # *
Email *
Any change in dental health since last visit? *
Any changes in medical history since last visit?
Any surgeries or hospitalizations since last dental visit? *
If you answered yes to recent hospitalization, then please describe situation.  
Do you have any heart conditions? *
Are you taking any prescription medications? *
If you answered yes above. What prescriptions are you taking?
Are you taking bisphosphonates, antiresorptive, or antiangiogenic drugs (medicines that affect bone growth or metabolism)?
Do you currently take an antibiotic premedication prior to your dental appointment?
Are you allergic to any medications, foods, or latex? *
If you answered yes to allergies then please specify below
Do you use any tobacco products?
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Female Patients: Are you pregnant?
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Female Patients: Are you breastfeeding?
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I certify that I have read, and understand the questions above. I acknowledge that my questions, if any, about the inquiries above have been answered to my satisfaction. I will not hold my doctor, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form. 

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