Patient Information Update Form

Do you have a new address?

• Yes
• No

Please update your emergency contact information:

Have you changed employers?

• Yes
• No

Has your primary dental insurance changed?

• Yes
• No

Has your secondary dental insurance changed?

• Yes
• No

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

Are you allergic to any of the following?

• Latex
• Codeine
• Antibiotics (list below)
• Dental anesthetics (list below)

List any other allergies:

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

• Yes
• No

Are you pregnant or nursing?

• Yes
• No

Are you taking birth control pills?

• Yes
• No

Do you smoke?

• Yes
• No

Do you have diabetes?

• Yes
• No

Do you get headaches?

• Yes
• No

Do you have any artificial joints?

• Yes
• No

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

• Yes
• No

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