Medical History Update Patient Name*Date of Birth*Parent(s) / Guardian*Social Security Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneWork PhoneEmail Address* Name Of Physician*Date Of Last Medical Exam*Are You Under The Care Of A Physician? Why?*Are You Taking Any Medications? Please List*Do You Need Pre-Med (antibiotics) Before Dental Treatment?*Do You Or Have You Ever Had Any Of The Following?Select All That Apply Heart Disease High Blood Pressure Stroke Artificial Valve / Joints Respiratory Problems Diabetes Epilepsy Allergies to Medicine Pregnancy Aids (HIV) Rheumatic Fever Hepatitis Ulcers Abnormal Bleeding Mental Disorders Cancer Radiation Treatment Tuberculosis Are You Allergic To Any Medications? List*Have You Had Any Recent Surgery, Or Been Hospitalized?*Is There Anything Else We Should Know About Your Medical History?*Has Your Insurance Information Changed?*Patient / Guardian Signature*Date* Date Format: MM slash DD slash YYYY
