Updated Medical History Form

UPDATED MEDICAL HISTORY

Select a Location*

Patient Type

Self Identification

ManWomanOtherNon-Binary

Name of Patient

Date of Birth

Address

Home Phone

Cell Phone

Work Phone

Best number to reach you at?

HomeCellWork

Are you currently being treated for any medical condition or have you been treated within the past year?*

YesNo

Please Explain further Details

When was your last medical checkup?*

Has there been any change in your general health in the past year?*

YesNo

Please Explain further Details

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

YesNo

Please Explain further Details

Do you have any allergies?*

YesNo

Please list allergies below.

Have you ever had a peculiar or adverse reaction to any medicines or injections?*

YesNo

Please Explain further Details

Do you have or have you ever had asthma?*

YesNo

Do you have or have you ever had any heart or blood pressure problems?*

YesNo

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?*

YesNo

Do you have a prosthetic or artificial joint?*

YesNo

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

YesNo

Have you ever had hepatitis, jaundice or liver disease?*

Yesno

Have you ever been hospitalized for any illnesses or operations?*

YesNo

Do you have or have you ever had any of the following? Please check all that apply.

chest pain, anginarheumatic feverpacemakersteroid therapyseizures (epilepsy)heart attackmitral valve prolapselung diseasediabeteskidney diseasestroke, TIAtuberculosisstomach ulcersthyroid diseaseshortness of breathheart murmurcancerarthritisdrug/alcohol/cannabis use or dependencyosteoporosis medications (e.g. Fosamax, Actonel)loss of hearingdifficulty hearing

Are there any conditions or diseases not listed above that you have or have had?

YesNo

Please Explain further Details

Do you smoke or use other nicotine products?

YesNo

Are you breastfeeding or pregnant?

YesNo

If pregnant, what is the expected delivery date?

Do you identify as a patient with a disability?

YesNo

Please Explain further Details

General Release

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history to the best of my ability and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.*

Signature

Use your mouse or finger to draw your signature above

Date