Medical Information Update
Gender
Is patient a minor?
Birthdate
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Did he/she refer you to our office?
Parent/Guardian #1
Birthdate
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Add 2nd Parent/Guardian
Parent/Guardian #2
Birthdate
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Medical Details
Does the patient have or has he/she ever had:
ADHD
Diabetes
Pacemaker
Abnormal Blood Pressure
Epilepsy
Prolonged Bleeding
Anemia
Frequent Headaches
Radiation Therapy
Arthritis
HIV+/AIDS
Rheumatic Fever
Asthma or Breathing Problem
Heart Disease
Sinus Trouble/Hay Fever
Autism
Heart Murmur
Stroke
Autoimmune Disorder
Hepatitis or Liver Problems
Tuberculosis or Lung Disease
Cancer or Leukemia
Herpes/Venereal Disease
Ulcers
Congenital Heart Defect
Osteoporosis
Does the patient have or has he/she ever had Allergies to:
Latex
Local Anesthetic
Allergy to Other Medication
Other Allergies
Pregnant (if yes, due date)?
Due Date
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By signing below, I certify that the information I have provided today is complete and accurate. I also understand that it is my responsibility to inform the office of any changes regarding my (or my child's) medical health.
Date
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