Medical History Update Patient Name* Date of Birth* Parent(s) / Guardian* Social Security Number* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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* MM slash DD slash YYYY
