Medical History Update
Brantford Central Dental
Personal Information
First name
*
Valid first name is required.
Last name
*
Valid last name is required.
Date of Birth (yyyy-mm-dd)
*
Please select/type a valid date.
Gender
Choose...
Male
Female
Other
Please select gender.
Do you need update your address?
*
Yes
No
Address
Please enter your address.
Address 2
City
Please provide a valid city name.
Province
Choose your province
ON
AB
BC
MB
NB
NL
NS
NT
NU
PE
QC
SK
YT
Please provide a valid province.
Zip
A valid zip code is required.
Tel: Home
*
Please provide a valid phone number.
Cell:
Same as home
Business
Email
*
Please provide a valid email address.
1. Do you need update your physician/Specialist information?
*
Yes
No
Physician/Specialist
Tel:
2. Do you need update your emergency contact?
*
Yes
No
Emergency Contact
Tel:
Cell
3. Do you need add or update your dental insurance?
*
Yes
No
Insurance Card Front(Max size 10M)
File size exceeded max limit.
Insurance Card Back(Max size 10M)
File size exceeded max limit.
Medical History
Your answers are for our records only and will be confidential.
1. Are you being treated for any medical condition or have you been treated or hospitalized for any illnesses or operations?
*
Yes
No
2. When was you last medical check-up?
3. Are you take any medication?
*
Yes
No
4. Do you have any allergies?
*
Yes
No
Medications (penicillin, local anesthetics, Asprin, etc)
Latex (rubber products)
Others (e.g. foods)
5. Have you ever had a peculiar or adverse reaction to any medicines or injections?
*
Yes
No
6. Do you have any family history of diseases or medical problems?
*
Yes
No
7. Do you have any conditions or therapies that could affect your immune system?
*
Yes
No
Leukenia
AIDS
Radiotherapy
Chemotherapy
Other
8. Do you have or have you ever had heart problem or artificial joint? If yes, please check
Artificial heart valve
Prosthetic/artificial joint
Heart condition from birth
Heart transplant
Infection of the heart (i.e. infective endocarditis)
Other
9. Do you have or have you ever had any of the following? If yes, please check
Asthma/hayfever
Angina/heart attack
Arthritis
Bleeding problem
Hepatitis/liver disease
Kidney disease
High blood pressure
Low blood pressure
Blood thinner
Shortness of breath
Stroke
Heart murmur/pacemaker
Heart valve problem
Rheumatic fever
Stomach ulcers
Lung disease
Diabetes
Seizures(epilepsy)
Thyroid disease
Steroid/cortisone
Drug/alcohol dependency
Osteoporosis medications(e.g. fosamax, actonel)
Others
10. Do you smoke or chew tobacco product?
*
Yes
No
11. For women only: Are you breastfeeding or pregnant?
Yes
No
When is the expected due date?
Informed Consent/General Release
*
I, the undersigned, state that I have provided an accurate and complete Medical/Dental history and have not knowingly omitted any information. I consent to my physician being contacted if neccessary. I agree, in accordance with the rules of the Privacy Act, your office may collect, use and disclose my personal information as required, I autrhorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anaesthetic as may be neccessary, I also understand that I assume resposibility for any and all fees associated width these procedures and services provided to me or my dependants.
Please sign here:
*
Clear Signature
Submit