Harvard Rd Dental Care - Patient and Medical History

Patient History

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* 1. Full name:

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* 2. Nickname:

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* 3. Date of Birth:

Date / Time

Date

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* 4. What is your gender?

Female

Male

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* 5. Address and contact information:

Address

Address 2

City/Town

Province

Postal Code

Country

Email Address

Phone Number

Medical History

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* 6. Are you in Good Health?

Yes

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* 7. Do you have a physician?

Yes

What is the name of your physician?

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* 8. Have you had any illnesses, operations, or have been hospitalized in the past 5 years?

Yes

Please list the illnesses and or operations.

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* 9. Do you have, or have had any of the following medical conditions or procedures?

Rheumatic fever

Bleeding tendency

Mitral valve prolapse

Heart murmur

Snoring/Sleep Apnea

Asthma

Low blood sugar

Hayfever/sinus problems

Kidney trouble

Are you on dialysis

Respiratory problems

Tuberculosis

Jaundice/Liver disease

Hepatitis

Arthritis/Joint disease

High blood pressure

Low blood pressure

Infectious mononucleosis

Gallbladder trouble

Stomach Ulcers

Chest pain/angina

Emphysema

Fainting spells

Heart attack(s)

Irregular heart beat

Cardiac pacemaker

Damaged heart valves

Heart surgery

Blood transfusion

Stroke

Convulsions/epilepsy

Thyroid issues

Delay in healing

Bruise easily

Diabetes

Eye disease/Glaucoma

Bronchitis/Chronic Cough

Anemia

Chronic fatigue/Night sweats

Sexually Transmitted Disease

Contact lenses

Swollen ankles

Contagious diseases

Do you smoke

Do you use cannabis

Do you use chewing tobacco

Do you have a history of drug abuse

Malignant hyperthermia

Tumour or growth

Radiation/Chemotherapy

Blood disorder

Immune system problems or disorders

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* 10. Allergies to the following:

Penicillin

Amoxicillin

Local anesthetic

Valium or other sedatives

Codeine or other narcotics

Sulfites

Sulfa drugs

Sodium pentothal

Aspirin

Latex

Eggs/Yolk

Soy

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* 11. Please List any Other allergies not mentioned including Non-Drug allergies:

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* 12. The following questions are for women:

Is there a possibility you are pregnant

Are you nursing

Are you taking birth control pills

If you are pregnant, when is your due date?

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* 13. For all patients
Are you taking any of the following:

Nerve pills

Muscle relaxers

Diet pills

Insulin

Blood thinners

Pain killers (including aspirin)

Stimulants

Tranquilizers

Antidepressants

Bone density meds or Bisphosphonates

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* 14. Please list any other medications you are taking. Please include Natural, Herbal, Homeopathic products and Vitamins.

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* 15. Please verify that the information above is correct and to the best of your knowledge.

Agree

Disagree

Harvard Rd Dental Care - Patient and Medical History

Patient History

Question Title

* 1. Full name:

Question Title

* 2. Nickname:

Question Title

* 3. Date of Birth:

Question Title

* 4. What is your gender?

Question Title

* 5. Address and contact information:

Question Title

* 6. Are you in Good Health?

Question Title

* 7. Do you have a physician?

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* 8. Have you had any illnesses, operations, or have been hospitalized in the past 5 years?

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* 9. Do you have, or have had any of the following medical conditions or procedures?

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* 10. Allergies to the following:

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* 11. Please List any Other allergies not mentioned including Non-Drug allergies:

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* 12. The following questions are for women:

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* 13. For all patients Are you taking any of the following:

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* 14. Please list any other medications you are taking. Please include Natural, Herbal, Homeopathic products and Vitamins.

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* 15. Please verify that the information above is correct and to the best of your knowledge.

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* 16. Thank you for completing your patient and medical form. We appreciate it and are looking forward to seeing you soon!

* 13. For all patients
Are you taking any of the following: