Health History Update Step 1 of 2 50% Patient Name(Required)Phone Number(Required)Email(Required)Personal Physicians Name(Required)Have you been hospitalized within the past 2 years?(Required) Yes No If yes, for what?Are you currently being treated by a physician?(Required) Yes No If yes, for what?Are you currently taking any medications or drugs?(Required) Yes No If yes, what?Have you ever received counseling for excessive use of alcohol and/or prescription drugs?(Required) Yes No Are you allergic to any drugs?(Required) Yes No If yes, what?Are you allergic to any metals or latex?(Required) Yes No If yes, what?Do you bleed excessively upon injury?(Required) Yes No Do you currently or have you ever used tobacco in any of the following forms?(Required) None Vaping Smoking Chewing Are you Pregnant?(Required) Yes No Do you use a tooth whitener?(Required) Yes No Check any of the following conditions that you have had or now have.(Required) None AIDS Heart Murmer Heart Problem* Hepatitis Psychiatric Care Sexually Transmitted Diseases Osteoporosis Stroke Tuberculosis Other Diseases Any other diseases? PERSON TO BE CONTACTED IN CASE OF EMERGENCYName(Required)Relationship(Required)Phone Number(Required)
