Health History Update Step 1 of 2 - Personal Information 50% Patient's Name Date MM slash DD slash YYYY Phone NumberEmail Personal Physicians Name Have you been hospitalized within the past 2 Years? Yes No If yes, for what? Are you currently being treated by a physician? Yes No If yes, for what? Are you currently taking any medications or drugs? Yes No If yes, what? Have you ever received counseling for excessive use of alcohol and/or prescription drugs? Yes No Are you allergic to any drugs? Yes No If yes, what? Are you allergic to any metals or latex? Yes No If yes, what? Do you bleed excessively upon injury? Yes No Do you currently or have you ever used tobacco in any of the following forms? Vaping Smoking Chewing Are you pregnant? Yes No Have you used a tooth whitener? Yes No Are you happy with the appearance of your smile? Yes No If no, why not? Check Any of the Following Conditions That You Have Had or Now Have AIDS Arificial Joint Asthma Cancer Diabetes Heart Murmur Heart Problem* Hepatits High Blood Pressure Kidney Problems Low Blood Pressure Psychiatric Care Sexually Transmitted Diseases Osteoporosis Stroke Tuberculosis Other Diseases* Other Diseases Name of Person to Be Contacted in Case of Emergency Relationship Home Phone NumberWork Phone Number
