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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