Health History Update
Contact Information
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Female
Male
Non-Binary/Other
Unspecified/Prefer Not To Answer
Date of Birth
Address
Address 2
Province/State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Other
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Relation
Emergency Phone #
Medical History
Do you have any allergies?
Yes
No
If any, please list
Name of Physician
Name of Pharmacy
Have you experienced any unusual reaction to any of the following drugs?
Penicillin
Codeine
Aspirin
Local Anesthetic
NSAIDS (Ibuprofen)
Other
Please specify
Please list any medications you are currently taking
Are you taking Warfarin or Coumadin?
Yes
No
Are you currently or have you taken Fosamax
Yes
No
Have you ever had any of the following diseases / conditions?
Tuberculosis
Heart Disease
Mitral Valve Prolapse
Pacemaker
Diabetes
Hep A/B/C
Epilepsy
Joint / Valve replacement
Persistent cough
HIV
Are you allergic to Latex?
Yes
No
Details
Do you currently use Tobacco?
Yes
No
Details
Do you bruise easily; take a long time to heal from cuts?
Yes
No
Details
Are you pregnant?
Yes
No
What is the due date?
Do you have any concerns that are not listed above that you feel we should know about? Please list.
Do you require extra freezing or premedication prior to dental appointments?
Yes
No
Details
Do you require Nitrous Oxide (laughing gas) prior to dental appointments?
Yes
No
Details
