Medical Update Form | Carolina Orthodontics & Children's Dentistry

PATIENT MEDICAL HISTORY UPDATE

Patient Name

Date of Birth

All information provided here is 100% confidential and any attempt to conceal preexisting conditions or other relevant information could result in serious patient drug interactions or death. The following questions must be answered honestly so that our office can provide you with the best possible care.

Please check the correct response :

1. Have you ever been seriously ill since your last office visit?

Yes

2. Have there been any changes in your medical history since your last office visit?

Yes

If yes, please explain:

3. Is a medical doctor currently treating you?

Yes

4. Primary care physician’s name:

Primary care physician’s phone number:

5. Please list any medication (Prescription or Over-the-Counter):

6. Are you allergic to, or have you had unusual reactions to any of the following?

Penicillin

Yes

Codeine

Yes

Sulfa Drugs

Yes

Aspirin

Yes

Latex

Yes

Barbiturates

Yes

Iodine

Yes

Erythromycin

Yes

No Known Allergies

Yes

7. Please check the box if you have ever been told you have any of the following:

Heart Defect

Yes

Anemia

Yes

Stroke

Yes

Infective Endocarditis

Yes

Depression

Yes

Jaundice

Yes

High Blood Pressure

Yes

Sinus Trouble

Yes

Frequent Headaches

Yes

Low Blood Pressure

Yes

Rheumatic Fever

Yes

Asthma

Yes

Diabetes

Yes

Hepatitis

Yes

Hay Fever

Yes

ADHD / ADD

Yes

Tuberculosis

Yes

Kidney Disease

Yes

Hives / Skin Rash

Yes

Active Infection

Yes

Swollen Neck Glands

Yes

Epilepsy

Yes

Autism

Yes

Thyroid Problems

Yes

Seizures

Yes

Other

Yes

Other:

I have read and understand the above questions. I have answered all of these questions truthfully to the best of my ability and knowledge. I consent to the diagnostic procedures and dentistry necessary for proper dental care.

Signature X