Patient Information Update Form

Personal Information

Do you have a new address?

Add new address here:

Please update your emergency contact information:

Changes to Employment & Insurance

Have you changed employers?

Has your primary dental insurance changed?

Has your secondary dental insurance changed?

Changes to Health History

List all medication you are currently taking and why you are taking them:

Are you allergic to any of the following?

List any other allergies:

Any changes in health status (hospitalizations, serious illness)?

Please describe health status changes:

Are you pregnant or nursing?

Are you taking birth control pills?

Do you smoke?

Do you have diabetes?

Do you get headaches?

Please indicate frequency & severity:

Do you have any artificial joints?

Please indicate date placed:

Do you snore, gasp for air, or wake up fatigued?

Describe anything specific you would like to talk to the doctor about today:

Sign & Date