Princess Dental Existing Patient Medical History Update Form



1. Are you currently under any medical treatment? *
2. Have you been admitted to a hospital or needed emergency care during the past two years? *
3. Are you currently taking any medications, including over-the-counter medications? *
4. Have you ever had any complications following dental treatment? *
5. Do you have or have had any of the following? Please check all that apply. *
6. Are there any conditions or diseases not listed above that you have or ever had? *
7. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer, or heart disease) *
8. Do you have a history of snoring/sleep apnea? *
If so do you use a mouth breather? *
Do you often find it difficult to breathe through your nose? *
Do you use a CPAP machine? *
9. WOMEN ONLY: Are you breastfeeding?
10. Are you pregnant?
12. Do you have any allergies to medications? *
13. Are you a sedation patient? *

For Sedation Patients Only

15. Do you have glaucoma? *
16. Do you have an allergy to Benzodiazepines? *
17. Have you received treatment for alcohol or drug use? *
18. Do you use narcotics or sedatives on a regular basis? *
19. Do you use recreational drugs? *
20. Is there any problem or medical condition that you wish to discuss in private only? *
Signature (Patient, Parent, or Guardian) *