Form E – Medical History Update

    1. Have you been admitted to a hospital or needed emergency care during the past two years?

    YesNo

    2. Are you taking any medication, drugs, or pills?

    YesNo

    3. Are you aware of having an allergy/reaction to any medication or substance?

    YesNo

    4. Do you need Antibiotics before Dental treatment?

    YesNo

    5. Do you smoke or chew tobacco products such as Cigarette, Marijuana, electronic cigarette?

    YesNo

    6. Please use a checkmark to indicate which of the following disease(s) you have had:

    Heart Disease:
    YesNo

    AIDS / HIV:
    YesNo

    Hay Fever:
    YesNo

    Radiation Therapy:
    YesNo

    High Blood Pressure:
    YesNo

    Hepatitis A, B, C, D:
    YesNo

    Diabetes:
    YesNo

    Lung disease:
    YesNo

    Heart Surgery / Attack:
    YesNo

    Anemia:
    YesNo

    Stroke:
    YesNo

    Liver Disease:
    YesNo

    Artificial Heart Valve:
    YesNo

    Hemophilia:
    YesNo

    Steroid Therapy:
    YesNo

    Kidney Trouble:
    YesNo

    Artificial Joints:
    YesNo

    Asthma
    YesNo

    Rheumatic Fever:
    YesNo

    Epilepsy / Seizures:
    YesNo

    Cancer / Tumor:
    YesNo

    Latex Sensitivity:
    YesNo

    Chemotherapy:
    YesNo

    Tuberculosis:
    YesNo

    Congenital heart condition:
    YesNo

    Drug/Alcohol dependency:
    YesNo

    Sleep Apnea:
    YesNo

    7. Do you have any disease or condition that is not listed above?

    YesNo

    Patient/Guardian Name:

    Please select the clinic: