UPDATED MEDICAL HISTORY FORM

Before completing this form, please ensure you have the following information ready:
Health Card number and expiry
Name and phone number of: Family Doctor, General Dentist, Medical Specialist, and Pharmacy
List of medications and allergies Primary and secondary insurance information (if applicable)

Title (Please circle one)*

Miss.

Mrs.

Ms.

Mr.

Dr.

Name of Patient*

First Name Last Name

Date Of Birth (DD/MM/YY)*

DD slash MM slash YYYY

Gender (Please circle one)*

Man

Woman

Other

Non-Binary

Address*

City*

Province*

Postal Code*

Mobile*

Phone Home

Height For sedation PurPoses

Weight For sedation Purposes

Health Card Number

Health Card Expiry

Mode of transportation home (After Surgery)

Post Surgery Pickup lnformation: (Name of ride and contact #)

Name*

Contact*

Do you have lnsurance lnformation to provide? Please circle one:

Yes

Do you have Secondary lnsurance to provide? Please circle one:

Yes

Patient Type (Please circle one below)

Adult Patient

Child Patient

Phone number of Parent / Guardian Person responsible for the account

Adult Patient

(Occupation/ Employer )

For Child Patient

(Name of Parent/ Guardian )

Family Doctor (Please write the Doctors name and phone number )

Doctor Name*

Doctor Phone Number

General Dentist (Please write the Dentists name and phone number)

Name

Phone Number

Pharmacy (Please write the pharmacy name and phone number)

Pharmacy Name

Phone Number

ln case of emergency, we should notify:

First Name

Last Name

List of medications, drugs (prescription or non-prescriptive ), herbar supplements:

When was your last medical checkup? (DD/MM/YY)

Emergency contact relationship: Are you currently being treated for any medical condition, or have you been treated within the past year? Please circle:

Yes

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

Yes

Are you taking any medjcations, non-prescription drugs, or herbar supplements of any kind? please circle yes or no below. If circle yes,Please list all the medication, prescription or non-prescription drug and herbal supplements:

Yes

Do you have any allergies? please circle

Yes

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

Yes

Please list:

Do you have or have you ever had asthma? please circle

Yes

Do you have or have you ever had any heart or blood pressure problems? please circle:

Yes

Please list:

Do you have or have you ever had any of the following? Please clrcle all that apply, 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?

Do you have a prosthetic or artificial joint? Please circle:

Yes

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

Yes

Have you ever had hepatitis, jaundice, or liver disease? Please circle:

Yes

Do you have a bleeding problem or bleeding disorder? Please circle:

Yes

Have you ever been hospitalized for any illnesses or operations? Please circle:

Yes

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

Yes

Do you have or have you ever had any of the following?

Select the Following

Chest pain

Angina

Rheumatic fever

Pacemaker

Steroid therapy

Seizures (epilepsy)

Heart attack

Mitral valve prolapse

Lung disease

Diabetes

Kidney disease

Stroke

TIA (Transient Ischemic Attack)

Tuberculosis

Stomach ulcers

Thyroid disease

Shortness of breath

Heart murmur

Cancer

Arthritis

Drug/alcohol/cannabis use or dependency

Osteoporosis

Medications (e.g., Fosamax, Actonel)

Loss of hearing Difficulty hearing

lf you consume alcohol, how many times a week? prease circre:

Everyday

Every other day

Every week

A few times a month

Do you or have you ever smoked or chew tobacco products? Please circle:

Yes

Do you or have you ever taken bisphosphonates or other anti_resorptive/bone strengthening medications?

Yes

Do you use recreational drugs? lf your answer is yes, how many times a week? please below: circle and answer

Yes

how many times a week?

WOMEN ONLY

Are You ?

Pregnant

Nursing

Taking birth control

Do you clench or grind your teeth? please circle one

Yes

Have you been diagnosed with sleep apnea? please circle one

Yes

Have you ever had orthodontic treatment (Braces or lnvisalign? please circle one:

Yes

Have you experienced any jaw injuries? please circle one:

Yes

Have you ever had implant surgery in your jaw? prease circre one

Yes

Have you ever had any complications or issues with previous dental treatment?

Please list anything below else not mentioned above regarding your past dental history:

Do you have lnsurance lnformation to provide? Please circle one:

Yes

Do you have Secondary lnsurance to provide? Please circle one:

Yes

Cancellation/Missed Appointments

Your appointment time has been reserved exclusively for you to see the specialist, We ask that you give us at least 5 business days' notice when cancelling your scheduled appointment so that we may offer the time to another patient. lf you must cancel or change your appointment, please call 613-831-8000.

General Release

l, 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 quesiions 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 ihe laws of the province of Ontario.

Name

First Name Last Name

Signature