Existing Patient Update Form Download Printable Version "*" indicates required fields Email* Date* MM slash DD slash YYYY As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.Patient InformationName* First Middle Initial Last If you are completing this form for another person, what is your relationship to that person? Your NameRelationshipHome PhoneCell PhoneMedical InformationAre you currently under the care of a physician? Yes No Date of last physical exam MM slash DD slash YYYY Physician NamePhone NumberAddress / City / State / ZipAre you in good health? Yes No Has there been any change in your general health within the past year? Yes No If yes, what condition is being treated?Do you use controlled substances (drugs)? Yes No Do you use tobacco (smoking, snuff, chew, bidis)? Yes No If so, how interested are you in stopping? Very Somewhat Not Interested Do you drink alcoholic beverages? Yes No If yes, how much alcohol did you drink in the last 24 hours?Have you had a serious illness, operation or been hospitalized in the past 5 years? Yes No If yes, what was the illness or problem?Do you take any blood thinners? Yes No Do you take aspirin on a regular basis? Yes No Are you taking or have you recently taken any prescription or over the counter medicine(s)? Yes No If yes, please list all medications, including vitamins, natural or herbal preparations and/or diet supplementsHave you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement? Yes No If yes, dateIf yes, have you had any complications?Woman OnlyAre you pregnant? Yes No Number of weeksAre you taking birth control pills or hormonal replacements? Yes No Are you nursing? Yes No AllergiesPlease mark “Yes” if you are allergic to (or have had a reaction to) the following.Local anesthetics* Yes No Aspirin* Yes No Penicillin or other antibiotics* Yes No Barbiturates, sedatives, or sleeping pills* Yes No Sulfa drugs* Yes No Codeine or other narcotics* Yes No Metals* Yes No Latex (rubber)* Yes No Iodine* Yes No Hay fever / seasonal* Yes No Animals* Yes No Food / Other* Yes No If yes, please specifyHealth ConditionsPlease mark “Yes” if you have (or have had) any of the following diseases or problems. Heart murmur* Yes No Mitral valve prolapse* Yes No Artificial heart valves* Yes No Rheumatic fever* Yes No Cardiovascular disease* Yes No Angina* Yes No Arteriosclerosis* Yes No Congestive heart failure* Yes No Coronary artery disease* Yes No Damaged heart valves* Yes No Heart attack* Yes No Low blood pressure* Yes No High blood pressure* Yes No Congenital heart defects* Yes No Pacemaker* Yes No Rheumatic heart disease* Yes No Abnormal bleeding* Yes No Anemia* Yes No Blood transfusion* Yes No If yes, dateHemophilia* Yes No AIDS or HIV infection* Yes No Arthritis* Yes No Autoimmune disease* Yes No Rheumatoid arthritis* Yes No Systematic lupus erythematosus* Yes No Asthma* Yes No Bronchitis* Yes No Emphysema* Yes No Sinus trouble* Yes No Tuberculosis* Yes No Cancer / Chemotherapy / Radiation treatment* Yes No Chest pain upon exertion* Yes No Chronic pain* Yes No Diabetes type I or type II* Yes No Eating disorder* Yes No Malnutrition* Yes No Stroke* Yes No Glaucoma* Yes No Hepatitis, jaundice, or liver disease* Yes No Epilepsy* Yes No Fainting spells or seizures* Yes No Neurological disorders* Yes No If yes, please specifyGag Reflex Sensitivity* Yes No Sleep disorder* Yes No Kidney problems* Yes No Mental health disorders* Yes No If yes, please specifyRecurrent infections* Yes No If yes, please specifyNight sweats* Yes No Osteoporosis* Yes No Persistent swollen glands in neck* Yes No Severe headaches / migraines* Yes No Severe / rapid weight loss* Yes No STDs / STIs* Yes No Excessive urination* Yes No ADD* Yes No ADHD* Yes No Sensory Processing Disorder* Yes No Oral Sensory Sensitivity* Yes No Has a physician or previous doctor recommended that you take antibiotics prior to your treatment?* Yes No Do you have any disease, condition, or problem not listed above that you think we should know about?* Yes No If yes, please explainPharmacy InformationPharmacy NamePharmacy PhonePharmacy AddressSignatureNOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. Acknowledge Accuracy of Information* I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Name of Patient/Legal Guardian*Signature of Patient/Legal Guardian*Date* MM slash DD slash YYYY All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. For security purposes, please enter 728 in the field below.*CAPTCHA