Nhat Khanh Dentistry | 5296 University Ave, Suite I, San Diego, CA 92105 | (619) 265-2262

Medical History Update

Fields marked * are required

Patient Identification

Full Legal Name*

Date of Birth*

MM/DD/YYYY

Phone Number*

Approximate date of your last visit (if known)

MM/DD/YYYY

Have there been any changes?

Since your last visit, have any of the following changed?*No — nothing has changedYes — I have updates to share

Medication Changes

Have you started, stopped, or changed any medications?*No medication changesYes — medication changes

Current medications (include name, dose, and frequency)

Are you currently taking blood thinners or antiplatelet medications? (warfarin, Eliquis, Xarelto, Plavix, aspirin, etc.)*NoYes — please specify below

Which blood thinner / antiplatelet medication?

Are you currently taking, or have you ever taken, bisphosphonates (e.g., Fosamax, Boniva, Reclast, Prolia, Zometa)?*

No
Yes — oral (taken by mouth)
Yes — IV / infusion
Not sure

Health Condition Changes

Since your last visit, have you been diagnosed with any of these?

Diabetes (Type 1 or Type 2)
Heart condition (heart attack, angina, heart failure, valve disease)
High blood pressure (new diagnosis)
Stroke or TIA
Cancer (any type — please specify in notes)
Autoimmune disorder
Liver disease / hepatitis
Kidney disease
Lung disease (asthma, COPD, etc.)
Bleeding disorder
Osteoporosis / bone density loss
Pregnancy
Mental health condition
Other (specify in notes)

Have you had any surgeries, hospitalizations, or major medical procedures since your last visit?

Do you have any joint replacements (hip, knee, shoulder)?*NoYes

Have you been diagnosed with sleep apnea, or do you use a CPAP/BiPAP machine?*

No
Yes — diagnosed and treated
Yes — diagnosed but not treated
Suspected, not diagnosed

Are you taking a GLP-1 agonist (e.g., Ozempic, Wegovy, Mounjaro, Zepbound, Trulicity)?*NoYes

Has any doctor told you that you need to take antibiotics before dental procedures?*NoYes — please specify belowNot sure — please ask my doctor

Details on premedication (which antibiotic, who prescribed, why)

Allergies

Any new allergies since your last visit?*No new allergiesYes — new allergies

All current allergies and reaction type (medications, latex, foods, materials)

Lifestyle and Contact Info

Current tobacco / nicotine use*

Information about cannabis use is collected for your dental safety only (e.g., interactions with sedation, dry mouth, oral cancer screening). Under California Civil Code § 56.108, this information will not be disclosed to third parties without your separate written authorization.

Has your address, phone, or insurance changed?*No — same as last visitYes — please update below

Updated contact information

Today's Dental Concerns

Anything specific you want the dentist to look at today?

Attestation

I understand that the information I provide on this form becomes part of my dental record. California law (16 CCR § 1681) requires the practice to retain this record for at least seven years after my last visit (or, if I am a minor, until I turn 25). My record is protected by HIPAA and the California Confidentiality of Medical Information Act (Civil Code § 56 et seq.).

To the best of my knowledge, the information I have provided is accurate and complete. I understand that providing inaccurate or incomplete information may put my health at risk during dental treatment and may compromise the validity of my informed consent. I further understand that knowingly providing false information to obtain insurance benefits is a crime under California Penal Code § 550.

I will notify the dental team of any further changes to my medical history, medications, or allergies before or during my treatment today.

Signer is…*The patient (self, 18 or older)Parent or legal guardian (for minor patient)Power of Attorney / Conservator

Signature*

Signature

Date Signed*

MM/DD/YYYY

Witness / Staff Member Name (printed)

Optional — leave blank if no staff member is present (e.g., filling at home). Staff can add their name later in the office.

Witness / Staff Signature

Signature

Nhat Khanh Dentistry | 5296 University Ave, Suite I, San Diego, CA 92105 | (619) 265-2262

Medical History Update

Fields marked * are required

Patient Identification

Full Legal Name*

Date of Birth*

MM/DD/YYYY

Phone Number*

Approximate date of your last visit (if known)

MM/DD/YYYY

Have there been any changes?

Since your last visit, have any of the following changed?*No — nothing has changedYes — I have updates to share

Medication Changes

Have you started, stopped, or changed any medications?*No medication changesYes — medication changes

Current medications (include name, dose, and frequency)

Are you currently taking blood thinners or antiplatelet medications? (warfarin, Eliquis, Xarelto, Plavix, aspirin, etc.)*NoYes — please specify below

Which blood thinner / antiplatelet medication?

Are you currently taking, or have you ever taken, bisphosphonates (e.g., Fosamax, Boniva, Reclast, Prolia, Zometa)?*

No
Yes — oral (taken by mouth)
Yes — IV / infusion
Not sure

Health Condition Changes

Since your last visit, have you been diagnosed with any of these?

Diabetes (Type 1 or Type 2)
Heart condition (heart attack, angina, heart failure, valve disease)
High blood pressure (new diagnosis)
Stroke or TIA
Cancer (any type — please specify in notes)
Autoimmune disorder
Liver disease / hepatitis
Kidney disease
Lung disease (asthma, COPD, etc.)
Bleeding disorder
Osteoporosis / bone density loss
Pregnancy
Mental health condition
Other (specify in notes)

Have you had any surgeries, hospitalizations, or major medical procedures since your last visit?

Do you have any joint replacements (hip, knee, shoulder)?*NoYes

Have you been diagnosed with sleep apnea, or do you use a CPAP/BiPAP machine?*

No
Yes — diagnosed and treated
Yes — diagnosed but not treated
Suspected, not diagnosed

Are you taking a GLP-1 agonist (e.g., Ozempic, Wegovy, Mounjaro, Zepbound, Trulicity)?*NoYes

Has any doctor told you that you need to take antibiotics before dental procedures?*NoYes — please specify belowNot sure — please ask my doctor

Details on premedication (which antibiotic, who prescribed, why)

Allergies

Any new allergies since your last visit?*No new allergiesYes — new allergies

All current allergies and reaction type (medications, latex, foods, materials)

Lifestyle and Contact Info

Current tobacco / nicotine use*

Has your address, phone, or insurance changed?*No — same as last visitYes — please update below

Updated contact information

Today's Dental Concerns

Anything specific you want the dentist to look at today?

Attestation

I will notify the dental team of any further changes to my medical history, medications, or allergies before or during my treatment today.

Signer is…*The patient (self, 18 or older)Parent or legal guardian (for minor patient)Power of Attorney / Conservator

Signature*

Signature

Date Signed*

MM/DD/YYYY

Witness / Staff Member Name (printed)

Optional — leave blank if no staff member is present (e.g., filling at home). Staff can add their name later in the office.

Witness / Staff Signature

Signature