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Medical Update Form

PATIENT MEDICAL HISTORY UPDATE

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?
2. Have there been any changes in your medical history since your last office visit?
3. Is a medical doctor currently treating you?
6. Are you allergic to, or have you had unusual reactions to any of the following?
Penicillin
Codeine
Sulfa Drugs
Aspirin
Latex
Barbiturates
Iodine
Erythromycin
No Known Allergies
7. Please check the box if you have ever been told you have any of the following:
Heart Defect
Anemia
Stroke
Infective Endocarditis
Depression
Jaundice
High Blood Pressure
Sinus Trouble
Frequent Headaches
Low Blood Pressure
Rheumatic Fever
Asthma
Diabetes
Hepatitis
Hay Fever
ADHD / ADD
Tuberculosis
Kidney Disease
Hives / Skin Rash
Active Infection
Swollen Neck Glands
Epilepsy
Autism
Thyroid Problems
Seizures
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.


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