Sedation Medical History Update:



Medical History Update:

Name:_______________________________________________________ Birthday:______________________

Address:___________ _____________________________City:_____________State:________Zip:__________

Home Phone: _______________________Cell: _______________________Email: _______________________

|Please check Yes or No for the following: |

| Yes No Yes No Yes No |

|Yes No |

|AIDS | |Dizziness | |HIV Positive | |Scarlet Fever |

|Cervical Cancer | |Hepatitis A | |Radiation | |_______________________ |

|Chemotherapy | |Hepatitis B | |Respiratory | |_______________________ |

|Cortisone Medication | |Hepatitis C | |Rheumatic Fever | |_______________________ |

|Diabetes |

| Yes No Yes No Yes No |

|Yes No |

|Aspirin |

| Yes No Yes No Yes No |

|Yes No |

Actonel | |Fosamax | |Zometa | |Herbal Supplements | | |Aredia | |Reclast | |Boniva | | | | |

Have you had a visit to a physician since your last dental visit? Yes No

Women: Are you pregnant? Yes No Are you a nursing mother? Yes No

Please list any medications you are currently taking:

1_________________________________ 2_________________________________ 3_________________________________ 4_________________________________

5_________________________________ 6_________________________________

Would you like to make any changes to your Smile Reminder or your HIPAA forms? Yes No

Signature_____________________________________________________________ Date:_________________________

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