Medical History Update Date of Last Visit to Medical Doctor(Required) Reason for Medical Doctor Visit: Please list your current medications: Please list all known allergies (medications, foods, latex, environmental, contrast dye, etc.).(Required) If any allergies listed above: please list the allergen/reaction/and severity(mild, severe, life-threatening)(Required)Since your last health history in this office, have you been hospitalized or had any surgeries, including artificial joints or valves? If so, please list: Please list any surgeries/ hospitalizations/new diagnosis: Do you require antibiotics before dental visits? Yes No Do you smoke or use tobacco in any form? Yes No If you checked yes on the question above, how much/many per day? Date MM slash DD slash YYYY Consent I agree to the privacy policy.Name First Last
