Medical update form for 13 years and plus patients

Patient’s first name *

Patient’s last name *

Nickname

Date of birth *

Patients’s Physician/Pediatrician *

Physician’s Phone Number *

Are you presently under the care of a physician or health care professional? *

Please explain *

Have you ever been hospitalized, had surgery, or had other significant injury or illness? *

Please explain *

Is there a history of problems with sedation and/or anesthesia? *

Please specify *

Please list any medications that you are currently taking. (Prescription, vitamins, supplements, or natural products)

Are there any allergies or reactions? *

If yes, a list will appear. Click any application allergies or reactions.

Please list *

Aspirin
Pollen/Dust
Local Anesthetics
Penicillin or other antibiotics
Food
Dyes
Latex
Metals
Others

Please list foods your child is allergic to *

Other allergies *

Have you ever been diagnosed as having any conditions? *

If yes, a list of conditions will appear. Check any applicable condition(s).

Please list *

Autism Spectrum Disorder
Anxiety/Depression
ADD/ADHD/ODD
Asthma/Breathing Problems
Acid Reflux/Stomach Issues
Birth Defect or Syndrome
Bladder/Kidney Problem
Blood Disorders
Bone or joint problems
Cancer/Tumor
Cerebral Palsy
Chronic Ear Infections
Hearing/Speech Impairment
Cleft lip/palate
Convulsion/Seizures
Delayed growth/Problem Stature
Development birth defect /syndrome
Diabetes
Disability/Physical
Down Syndrome
Eating Disorders
Eye Problems
Emotional Disturbance
Heart Problem/Surgery
Headaches/Migraine
Spina Bifida
Heart Murmur
Hemophilia
HIV/AIDS
Hormonal Issue (Thyroid)
Learning Disability
Oral Ulcers
Premature Birth
Sickle cell anemia
Sleep Apnea/Snoring
Skin Issues
Malignant Hyperthermia
Family history of Malignant Hyperthermia
Other

Other conditions *

Are you pregnant? *

Do you smoke or chew tobacco? *

Do you drink Alcohol? *

Do you have or had oral piercings? *

Are there any dental concerns, or anything you would like to change about your teeth? *

Please specify *

The permission of parent or guardian is necessary for dental treatment of a minor. I understand that all the above information I have given is correct and accurate, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I consent to the performing of dental procedures agreed to be necessary or advisable for my child. I also consent that my child’s radiographs, dental and facial photographs and dental models be kept in our files and be used for treatment planning and follow-up, patient/parents education and medical/dental lectures.

Signature of Patient *

Date *

Signature of Parent/Guardian (optional)

Relationship to patient

Date

Notice *

Signature *

Medical Update Teen Form

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