Key West Dental Associates

3146 Northside Drive Key West, Florida 33040


Annual Update Form for Current Patients

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable lows. Please note that you will be asked about responses to this questionnaire and there may be additional questions concerning your health. This information is vital and to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Personal Information

First Name:
Last Name:
Cell Phone:
Birth Date:
Home Phone:
Work Phone:
E-Mail Address:
Zip Code:
Did your Dental insurance change?

Dental Information:

Has your dental health changed since your last visit?
Are you here for routine care?
Did you want to address a specific dental need today with your dentist?

Medical Information:

Allergies: Please check “yes” or “no” to any allergies you have.:

Local Anesthetics:
Codeine/other narcotics:
Latex (rubber):
Sulfa Drugs:
Hay fever/Seasonal:
Sedatives/sleeping pills:
If Other 'Yes', explain:
Do you or have you had Multiple myeloma or metastatic cancer?
Date Treatment began:
Joint Replacement: Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
If yes, have you had any complications?
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax, Actonel, Atelvia, Bonivia, Reclast, Prolia) for osteoporosis or Paget’s disease?
Since 2001, were you treated or are you presently scheduled to begin taking an antiresorptive agent (like Aredia, Zometa, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease?
Has a physician or previous dentists recommended that you take antibiotics prior to your dental treatment?
Name of physician or dentist making recommendation
Phone number

For Women Only:

Are you pregnant?
Are you nursing?
Using birth control pills or hormone replacement therapy?

Please check “yes” or “no” :

Do you wear contact lenses?
Do you use controlled substances (drugs)
Do you use tobacco (smoking, snuff, Chew, Bidis)?
If so, how interested are you in stopping?
Do you drink alcoholic beverages?
If yes, how much did you drink in the last 24 hours?
If yes, how much do you typically drink in a week?
Are you now under the care of a physician?
Physician Name
Has there been any change in your health within the past year?
If yes, please explain
Have you had a serious illness, operation or been hospitalized in that past 2 years?
If yes, please explain
Are you taking or have you recently taken any prescription or over the counter medicine?

If yes, please list all, including vitamins, natural or herbal preparation on/or dietary supplements:

Please check “yes” or “no” to indicate whether you have had or have any of the following conditions or diseases. If necessary explain yes answers below.:

Artificial Heart Valve
Congestive Heart Failure
Heart attack
Heart surgery
High cholesterol
Rheumatic fever
Excessive urination
Hepatitis/Liver Disease
Swollen neck glands
Neurological Disorder
Weight loss/gain
Congenital heart defect
Heart disease
Low blood pressure
Abnormal bleeding
Arthritis/Rheumatoid Arthritis
Gastrointestinal issues
Kidney problems
Sleep disorder
Mental disorder
Damaged heart valve
Heart Murmur/MPV
High blood pressure
Autoimmune disease
Eating disorder
Stomach Problems
Thyroid Problem
Snoring/Sleep apnea
Recurrent infections
Night sweats

Do you have any disease, condition, or problem not listed above that you think your dentist should know about? Please explain:

Note: Both doctor and patient(s) are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Regarding Cancellation and Missed Appointment

Please note, your appointment time is reserved just for you. A late cancellation or missed appointment leaves a hole in our schedule that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, are subject to a cancellation fee.

I Understand and Accept

Signature of Patient/Legal Guardian

Use your mouse cursor or the tip of your finger to sign below

Print Name:

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