Download Printable Version Existing Patient Update Form Today’s 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 InformationFirst Name Last Name Middle Initial Home PhoneCell PhoneEmail Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Height Weight Date of Birth MM slash DD slash YYYY SexMaleFemaleOccupation Emergency Contact How did you hear about us? If you are completing this form for another person, what is your relationship to that person?Your Name Relationship Home Phone Cell Phone Dental InformationAre your teeth sensitive to cold, hot, sweets or pressure? Yes No Do you have earaches or neck pains? Yes No Does food or floss catch between your teeth? Yes No Do you have any clicking, popping, or discomfort in the jaw? Yes No Is your mouth dry? Yes No Do you brux or grind your teeth? Yes No Have you had any periodontal (gum) treatments? Yes No Do you have sores or ulcers in your mouth? Yes No Have you ever had orthodontic (braces) treatment? Yes No Do you wear dentures or partials? Yes No Have you ever had any problems associated with previous dental treatment? Yes No Do you participate in active recreational activities? Yes No Are you currently experiencing dental pain or discomfort? Yes No Have you ever had a serious injury to your head or mouth? Yes No Chief ComplaintDate of your last dental exam MM slash DD slash YYYY What was done at that time? Date of last dental x-rays MM slash DD slash YYYY Reason for visit Dentist Name and # Medical InformationAre you in good health? Yes No Are you taking or have you recently taken any prescription or over the counter medicine(s)? Yes No Has there been any change in your general health within the past year? Yes No Women Only :If yes, what condition is being treated? Date of last physical exam MM slash DD slash YYYY If yes, please list all medications, including vitamins, natural or herbal preparations and/or diet supplements Do you have a history of chemical dependency? Yes No Are you Pregnant? Yes No Number of weeks Do you use controlled substances (drugs)? Yes No Taking birth control pills or hormonal replacements? Yes No Do you use tobacco (smoking, snuff, chew, bidis)? Yes No Nursing? Yes No Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.Local anesthetics Yes No Barbiturates, sedatives, or sleeping pills Yes No Metals Yes No Hay fever / seasonal Yes No Aspirin Yes No Sulfa drugs Yes No Latex (rubber) Yes No Animals Yes No Codeine or other narcotics Yes No Iodine Yes No Food / Other Yes No Penicillin or other antibiotics Yes No If yes, please specify Please mark "Yes" if you have (or have had) any of the following diseases or problems.Heart murmur Yes No Blood transfusion Yes No Diabetes type I or type II Yes No Mental health disorders Yes No If yes, date MM slash DD slash YYYY If yes, please specify Mitral valve prolapse Yes No Hemophilia Yes No Eating disorder Yes No Recurrent infections Yes No If yes, type of infection Artificial heart valves Yes No AIDS or HIV infection Yes No Malnutrition Yes No Kidney problems Yes No Rheumatic fever Yes No Arthritis Yes No Gastrointestinal disease Yes No Night sweats Yes No Cardiovascular disease Yes No Autoimmune disease Yes No GE Reflux / persistent heartburn Yes No Osteoporosis Yes No Angina Yes No Rheumatoid arthritis Yes No Ulcers Yes No Persistent swollen glands in neck Yes No Arteriosclerosis Yes No Systematic lupus erythematosus Yes No Thyroid problems Yes No Severe headaches / migraines Yes No Congestive heart failure Yes No Asthma Yes No Stroke Yes No Severe / rapid weight loss Yes No Coronary artery disease Yes No Bronchitis Yes No Glaucoma Yes No STDs / STIs Yes No Damaged heart valves Yes No Emphysema Yes No Hepatitis, jaundice, or liver disease Yes No Excessive urination Yes No Heart attack Yes No Sinus trouble Yes No Epilepsy Yes No ADD Yes No Low blood pressure Yes No Tuberculosis Yes No Fainting spells or seizures Yes No ADHD Yes No High blood pressure Yes No Cancer / Chemotherapy / Radiation treatment Yes No Neurological disorders Yes No Sensory Processing Disorder Yes No If yes, please specify Congenital heart defects Yes No Chest pain upon exertion Yes No Gag Reflex Sensitivity Yes No Oral Sensory Sensitivity Yes No Pacemaker Yes No Chronic pain Yes No Sleep disorder Yes No Rheumatic heart disease Yes No Anemia Yes No Abnormal bleeding Yes No Has a physician or previous dentist recommended that you take antibiotics prior to your dental 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 explain Pharmacy InformationPharmacy Name Pharmacy PhonePharmacy Address SignatureNOTE: NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.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. 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.Bp Smiles would like your permission to use images/videos taken of you or your child to showcase extraordinary before and after smiles for educational purposes and our office promotions on our website, Facebook, Instagram, office bulletin board, and other social media platforms. Please indicate below if we have your permission to use photos of you or your child. No protected health information will be released (as mentioned in the HIPAA Form).I grant permission for photos/images of me/my child to be used in the formats indicated above. I grant permission for photos/images of me/my child to be used in the formats indicated above.I DO NOT grant permission for photos/images of me/my child to be used in any of the formats indicated above. I DO NOT grant permission for photos/images of me/my child to be used in any of the formats indicated above.Name of patient Patient’s signature (if over 18 years) Date MM slash DD slash YYYY Parents/Guardian Name (if a minor) Signature of Parent/Guardian Date MM slash DD slash YYYY
