Medical History Update Name* First Last Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Female Medical History (if applicable)PregnantPregnant?YesNoNursingNursing?YesNoMenstruationHas menstruation begun?YesNoMedical HistoryMedical HistoryDo any of the following conditions apply to you? We need this information to ensure we keep you healthy and safe. No Health Conditions Medical History 2 Any Heart or Circulatory Condition Any Lung or Breathing Condition Any Digestive or Dietary Condition Any Neurological Condition Any Autoimmune Condition Anemia Cancer Diabetes Glaucoma Bleeding disorder/Hemophilia Hepatitis Jaundice or Liver Diseases Osteoporosis Renal/Kidney Problems Sleeep Apnea Sexually Transmitted Disease Total Joint Replacement Other (provide detail below) Heart ConditionsAbout your heart condition, can you provide more detail? Angina Artificial heart valve Arteriosclerosis Cardiovascular disease Congenital Heart Disease (CHD) Congestive heart failure Damaged heart valves Heart transplant High blood pressure Low blood pressure Heart attack Heart murmur Infective endocarditis Mitral valve prolapse Pacemaker Pulmonary embolism Rheumatic heart disease Other (provide detail below) Lung ConditionsAbout your lung or breathing condition, can you provide more detail? Asthma Bronchitis COPD Cystic Fibrosis Emphysema Tuberculosis Other (provide detail below) DigestiveAbout your digestive or dietary condition, can you provide more detail? Acid reflux/persistent heartburn Excessive urination Gastrointestinal disease Malnutrition Eating disorder Severe or rapid weight loss Special diet Other (provide detail below) NeurologicalAbout your neurological condition, can you provide more detail Autism Brain aneurysm Brain injury Epilepsy Fainting Migraines/severe headaches Seizures Stroke Other (provide detail below) AutoimmuneAbout your autoimmune condition, can you provide more detail? Ankylosing spondylitis Celiac disease HIV or AIDS Immune deficiancy Lupus Multiple sclerosis Rheumatoid arthritis Other (provide detail below) Other ConditionsMedicationsAllergiesAttestation of Completeness and Accuracy*I certify that I have read and understand the above. I acknowledge that I have completed the form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my dentist, orthodontist or any member of their staff responsible for any errors or omissions that I may have made. If there are any future changes to this history record, I will inform the practice. I agree to the statementsignature*signed @ ip address: 22.214.171.124 This iframe contains the logic required to handle Ajax powered Gravity Forms.