• Medical History Update Form

  • Date: (M/D/Y)*
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    2 digit month, 2 digit day, 4 digit year

  • In the past year, if your PERSONAL INFORMATION has changed please clarify below. If not, skip to MEDICAL HISTORY.

     

    Personal Information

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  •  Medical History

  • Are you currently taking any medications?*
  • In the past year, have there been changes in your medications?*
  • Are you allergic to any medications, food, latex or local anesthetics?*
  • Have you recently experienced any changes in your health?*
  • Have you been hospitalized or had surgery in the past 2 years?*
  • Do you require antibiotics before dental treatment?*
  • Have you ever been diagnosed with a heart murmur or heart defect?*
  • Do you have any prosthetic joints (hip or knee replacement)?*
  • Are you taking blood thinners (Coumadin, Warfarin, Plavix, Aspirin)?*
  • Have you ever fainted?*
  • Do you bruise easily or bleed excessively when cut?*
  • Are you pregnant?*
  • Have you ever been diagnosed with, or had symptoms related to any of the following?*

  • Centenary Dental will ensure that all information collected will be used for internal use only and will be kept secure and confidential. I consent to allow Centenary Dental to share my personal information with dental specialists if needed for the benefit of my care or to contact my medical doctor(s) if further information is needed to ensure my safety.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: