Download & Bring in Forms or Fill Online Dental History Form Download the printable PDF, fill it out, save and email to in**@ex*********.ca Medical History Form Download the printable PDF, fill it out, save and email to in**@ex*********.ca Medical History Name(Required) First Last Nickname AgePhysician's Name First Last Physician's Specialty Date of Most Recent Physical Examination MM slash DD slash YYYY Purpose of Examination What is your estimate of your general health? Excellent Good Fair Poor DO YOU HAVE or HAVE YOU EVER HAD:Hospitalization for illness or injury? Yes No Have you ever had an allergic reaction? Yes No I've had an allergic reaction to: aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride metals latex other I have allergic reactions to: nickel gold silver Other allergic reactions Heart problems, or cardiac stent within the last six months Yes No Arthritis Yes No History of infective endocarditis Yes No Autoimmune disease Yes No (i.e. rheumatoid arthritis, lupus, scleroderma)Artificial heart valve, repaired heart defect (PFO) Yes No Glaucoma Yes No Pacemaker or implantable defibrillator Yes No Contact lenses Yes No Orthopedic implant (joint replacement) Yes No Head or neck injuries Yes No Rheumatic or scarlet fever Yes No Epilepsy or convulsions Yes No (seizures)High or low blood pressure Yes No Neurologic disorders Yes No (ADD/ADHD, prion disease)A stroke (taking blood thinners) Yes No Viral infections and cold sores Yes No Anemia or other blood disorder Yes No Any lumps or swelling in the mouth Yes No Prolonged bleeding due to a slight cut (INR > 3.5) Yes No Hives, skin rash, hay fever Yes No Emphysema, shortness of breath, sarcoidosis Yes No STI / STD / HPV Yes No Tuberculosis, measles, chicken pox Yes No Hepatitis Yes No Type of hepatitis Breathing or sleep problems (i.e. sleep apnea, snoring, sinus) Yes No HIV / AIDS Yes No Kidney disease Yes No Tumor, abnormal growth Yes No Liver disease Yes No Radiation therapy Yes No Jaundice Yes No Chemotherapy, immunosuppressive medication Yes No Thyroid, parathyroid disease, or calcium deficiency Yes No Emotional difficulties Yes No Hormone deficiency Yes No Psychiatric treatment Yes No High cholesterol or taking statin drugs Yes No Antidepressant medication Yes No Diabetes Yes No HbA1c Digestive disorders Yes No (i.e. celiac disease, gastric reflux)Stomach or duodenal ulcer Yes No Osteoporosis/osteopenia Yes No (i.e. taking bisphosphonates)Alcohol / recreational drug use Yes No ARE YOU:Presently being treated for any other illness Yes No Aware of a change in your health in the last 24 hours Yes No (i.e. fever, chills, new cough, or diarrhea)Taking medication for weight management Yes No Taking dietary supplements Yes No Often exhausted or fatigued Yes No Experiencing frequent headaches Yes No A smoker, smoked previously or use smokeless tobacco Yes No Considered a touchy / sensitive person Yes No Often unhappy or depressed Yes No Taking birth control pills Yes No Currently pregnant Yes No Prostate disorders Yes No Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)List all medications, supplements, and or vitamins taken within the last two years.Drug Purpose Drug Purpose Drug Purpose Drug Purpose Drug Purpose Drug Purpose PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.Patient’s Signature Date MM slash DD slash YYYY 68413Δ
