4214 66 St NW, Edmonton, AB T6K 4A2 587-404-7677 780-463-8803 info@edmontonsmiles.net

Medical History Form

Please fill out our form below or click on the button to the right to download

1. Have you been under the care of a medical doctor during the past two years?
YesNo
Physician’s name
2. Have you taken any medication or drugs during the past two years?
YesNo
3. Are you taking any medications, drugs or pills now?
YesNo
4. Are you aware of having an allergic (or adverse) reaction to any medication or substance?
YesNo
5. Have you been in the hospital in the past five years?
YesNo
6. Indicate which of the following you have had, or have at present. Select “Yes” or “No” to each item.
Heart (Surgery, Disease, Attack)
YesNo
Hay Fever
YesNo
Chest Pain
YesNo
Lalnx Sensitivity
YesNo
Congenital Heart Disease
YesNo
Allergies or Hives
YesNo
Hear Murmur
YesNo
Sinus Trouble
YesNo
High Blood Pressure
YesNo
Iladiauon Tbenipy
YesNo
Mill Valve Pmlapse
YesNo
Chemotherapy
YesNo
Amficiat Heart Valve
YesNo
Tumours
YesNo
Heart Pacemaker
YesNo
Hepatiis A, B, C
YesNo
Rheumatic Fever
YesNo
Liver Disease
YesNo
Stroke
YesNo
Yellow Jaundice
YesNo
Swollen Ankles
YesNo
Venereal Disease
YesNo
Arthritis / Rheumatism
YesNo
AIDS
YesNo
Glauco
YesNo
Eniphysema
YesNo
Chronic Cough
YesNo
Tubcimilosis
YesNo
Asthma
YesNo
Sickle Cell Disease
YesNo
Bruise Easily
YesNo
Neurological Disorders
YesNo
Epilepsy or Seinues
YesNo
Fainting or Oizzy Spells
YesNo
Cortisone medication
YesNo
HN Positive
YesNo
Artificial Joints ‹hip, knee, etc)
YesNo
Blood Transfusion
YesNo
Kidney Trouble
YesNo
Hemopbilia
YesNo
Ulcers
YesNo
Diabetes
YesNo
Bruise Easily
YesNo
Thyroid Emblems
YesNo
Neurnlogical Disorders
YesNo
Nervous I Anxious
YesNo
Psychiatric / Psychological Care
YesNo
7. Do you have, or have you had disease, condition or problem not listed?
YesNo
8. WOMEN: Are you Pregnant?
YesNo
Taking Birth Control Pills?
YesNo


9. Do you smoke?
YesNo
I understand the above information is necessary to provide me with dental care in a safe, efficient manner. Should further information be needed. you have my permission to ask she respective health care provider or agency, who may release such information to you. I will notify the dentist or his staff of any change in my health or medication.

I, the undersigned, certify that I have provided an accurate and complete medical history and have not knowingly omitted any Information.

This is to certify that I, the undersigned, understand and agree with what I have read and consent to the performing of the dental procedures agreed to be necessary or advisable, including the use of local anesthesia. I agree to make payment for service upon completion, of each appointment, by cash, cheque or credit card unless other arrangements have been previously and specifically made with the dentist.

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