Existing PatientsPlease fill out the medical update form, place it in a sealed envelope, and bring it to your next appointment. Fill Out This FormPlease fill out all fields that apply. Medical History New Patient Name * Patient Age * Sex * Male Female OtherOther Date of Birth * Name of G.P. * Name of Specialist Date of Last Physical Examination * Weight * Height * Medical History Please check the appropriate box if you have ever been diagnosed (recently or in the past) for any of the following: Cardiovascular (Heart) High blood pressure (hypertension) Irregular heart beat, pacemaker (arrhythmia) Chest pain (angina) Heart attack (MI) Infectious endocarditis History of congenital heart disease Prosthetic heart valve Heart surgery: bypass, transplant, stent Hematologic (Blood) Anemia (not sickle cell) Bleeding disorder (not hemophilia) Bone marrow or stem cell transplant Blood transfusion Leukemia, Blood Cancer, Lymphoma, Multiple Myeloma Sickle Cell Anemia / trait Hemophilia Gastrointestinal (Digestive) Hepatitis Cirrhosis Ulcer(s) Transplant: Liver, Kidney Heartburn (Reflux) Irritable Bowel Crohn's or Ulcerative Colitis Nervous System Alzheimer's disease or other dementia: schizophrenia Depression, phobia or severe anxiety disorder Seizure / Epilepsy Headaches, frequent or severe Stroke (CVA) Degenerative disorders or paralysis Parkinson's, MS, Cerebral Palsy, Muscular Dystrophy Immune System Allergy to food, metals or jewelry Allergy to medicationAllergy to medication Allergy to latex HIV or AIDS Lupus Sjogren's syndrome Pulmonary (Lungs) Asthma Emphysema, Bronchitis Pneumonia Tuberculosis PPD+ History of BCG vaccination Endocrine Diabetes Thyroid - Hyper Thyroid - Hypo Prostate problem Adrenal disorder Cancer ANY history of cancer (breast, prostate, oral, lung, etc.) History of chemotherapy History of radiation therapy History of IV bisphosphonates Women I am pregnant or possibly pregnant I am nursing Post-menopause Oral contraceptive Musculoskeletal Artificial joint Degenerative Arthritis Rheumatoid Arthritis Osteoporosis Drug Use Prior or current injection drug use Prior or current non-injection recreational drug use Genitourinary (Kidneys, Urinary) Dialysis Syphilis, Gonorrhea, Herpes Dermatology (Skin) Rash / hives / sores Other Illnesses Any surgery, please specifyAny surgery, please specify Medications Medication Name Dosage Medication Name Dosage Medication Name Dosage Medication Name Dosage Medication Name Dosage If you take more than 5 medications please provide the name and telephone number of the pharmacy that you use Patient Signature To the best of my knowledge, all of the preceding answers concerning my medical history are complete and accurate. If there is a change in my health or in the medication I may be taking, I will immediately notify my dental care provider at my next appointment. Patient Signature * Date * Submit