Health History Update

Today's Date:
Patient First Name:
Last Name:
Date of Birth:
Email Address:
Phone Number:
Preferred Method of Contact:
Any recent dental changes, problems, or concerns?
If Yes, Please Explain:
Any recent changes in your health?
If Yes, Please Explain:
Any NEW allergies or sensitivities?
If Yes, Please Explain:
Any NEW medications? (Including over the counter)
If Yes, Please Explain:
For women: Are you pregnant?
If Yes, Please Explain:
Any changes to your personal representative?
If Yes, Please Explain:
Any changes to your dental insurance?
If Yes, Please Explain:
Last dental visit?
If Yes, Please Explain:
Social Media Consent?
If Yes, Please Explain:
Parent/Legal Guardian Signature:
Date:
Patient (If over 18yrs old) Signature:
Date: