Medical History Update

Full Legal Name*

Date of Birth*

Phone Number*

Approximate date of your last visit (if known)

Since your last visit, have any of the following changed?*

• No — nothing has changed
• Yes — I have updates to share

Have you started, stopped, or changed any medications?*

• No medication changes
• Yes — medication changes

Current medications (include name, dose, and frequency)

Are you currently taking blood thinners or antiplatelet medications? (warfarin, Eliquis, Xarelto, Plavix, aspirin, etc.)*

• No
• Yes — please specify below

Which blood thinner / antiplatelet medication?

Are you currently taking, or have you ever taken, bisphosphonates (e.g., Fosamax, Boniva, Reclast, Prolia, Zometa)?*

• No
• Yes — oral (taken by mouth)
• Yes — IV / infusion
• Not sure

Since your last visit, have you been diagnosed with any of these?

• Diabetes (Type 1 or Type 2)
• Heart condition (heart attack, angina, heart failure, valve disease)
• High blood pressure (new diagnosis)
• Stroke or TIA
• Cancer (any type — please specify in notes)
• Autoimmune disorder
• Liver disease / hepatitis
• Kidney disease
• Lung disease (asthma, COPD, etc.)
• Bleeding disorder
• Osteoporosis / bone density loss
• Pregnancy
• Mental health condition
• Other (specify in notes)

Have you had any surgeries, hospitalizations, or major medical procedures since your last visit?

Do you have any joint replacements (hip, knee, shoulder)?*

• No
• Yes

Have you been diagnosed with sleep apnea, or do you use a CPAP/BiPAP machine?*

• No
• Yes — diagnosed and treated
• Yes — diagnosed but not treated
• Suspected, not diagnosed

Are you taking a GLP-1 agonist (e.g., Ozempic, Wegovy, Mounjaro, Zepbound, Trulicity)?*

• No
• Yes

Has any doctor told you that you need to take antibiotics before dental procedures?*

• No
• Yes — please specify below
• Not sure — please ask my doctor

Details on premedication (which antibiotic, who prescribed, why)

Any new allergies since your last visit?*

• No new allergies
• Yes — new allergies

All current allergies and reaction type (medications, latex, foods, materials)

Current tobacco / nicotine use*

• Never used
• Used to use, but quit
• Currently smoke cigarettes
• Currently vape / e-cigarettes
• Currently chew tobacco
• Currently smoke or vape cannabis

Has your address, phone, or insurance changed?*

• No — same as last visit
• Yes — please update below

Updated contact information

Anything specific you want the dentist to look at today?

Signer is…*

• The patient (self, 18 or older)
• Parent or legal guardian (for minor patient)
• Power of Attorney / Conservator

Signature*

Signature

Date Signed*

Witness / Staff Member Name (printed)

Optional — leave blank if no staff member is present (e.g., filling at home). Staff can add their name later in the office.

Witness / Staff Signature

Signature