__________________________________________ __________________________________________ Relationship: _______________________________ Date of Birth (Day/Month/Year): ___ / ___ / ____ Address (Home): ____________________________ Name of Family Doctor __________________________________________ __________________________________________ City: ______________________________________ Phone Number or Address: Province: ___________ Postal Code: ____________ __________________________________________ __________________________________________ __________________________________________ Address (Work): _____________________________ (1) Name of Medical Specialist: __________________________________________ __________________________________________ City: ______________________________________ Area of Specialty: ___________________________ Province: ___________ Postal Code: ____________ Phone Number: (___) ____ - _______ __________________________________________ Area of Specialty: ___________________________ The fol owing information is required to enable us to provide you with the best possible dental care.
All information is strictly private, and is protected by doctor-patient confidentiality. The medical
professional wil review the questions and explain any that you do not understand.
Please fill in the entire form.
1. Are you being treated for any medical condition at the present or have you been treated within the past _______________________________________________________________________________________ _______________________________________________________________________________________ 3. Has there been any change in your general health in the past year? If yes, please explain. _______________________________________________________________________________________ To be completed by Medical Professional Only: 4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, _______________________________________________________________________________________ 5. Do you have any al ergies? If you answered yes, please list using the categories below: a) Medications ___________________________________________ b) Latex/Rubber Products ___________________________________________ c) Other (e.g. hay fever, foods) ___________________________________________ 6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain. _______________________________________________________________________________________ 7. Do you have or have you ever had asthma? 8. Do you have or have you ever had any heart or blood pressure problems? 9. 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 10. Do you have a prosthetic or artificial joint? 11. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy? 12. Have you ever had hepatitis, jaundice or liver disease? 13. Do you have a bleeding problem or bleeding disorder? 14. Have you ever been hospitalized for any il ness or operations? If yes, please explain. _______________________________________________________________________________________ 15. Do you have or have you ever had any of the following? Please check. To be completed by Medical Professional Only: 16. Are there any conditions or diseases not listed above that you have or have had? If so, what? _______________________________________________________________________________________ 17. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease) 18. Do you smoke or chew tobacco products? 19. Are you nervous during dental treatment? 20. For women only: Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?
_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
To the best of my knowledge, the above information is correct:
PATIENT/PARENT/GUARDIAN SIGNATURE: ___________________________________________________ DENTIST SIGNATURE: ___________________________________________________ DOCTOR/NURSE INITIALS: ___________________________________________________ To be completed by Medical Professional Only:


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