Medical History Update

Patient Name:

Are you currently being treated for any medical conditions? YesNo

If yes, please list conditions:

Please name all medications/supplements:

Please list Any allergies:

Have you been hospitalized for any reason within the past 2 years? YesNo

If yes, please explain why:

Do you require antibiotics prior to dental treatment?YesNo

Do you smoke tobacco or marijuana or use any recreational drugs? YesNo

List any countries you’ve visited in the past 3 months:

Family doctor name & phone number:

Date of last physical exam by family doctor:

Please indicate if you are recently being treated for or experiencing any of the following conditions: