15213 Yonge St, Suite 6 Aurora, ON L4G 1L8

Medical History Form

The following information is requested to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. In an effort to serve you better, we ask that you complete the following medical form. We will be glad to assist you with any questions you have.

PATIENT INFORMATION

Title:

Patient Name:*

In case of emergency, we should notify:

Are you being treated for any medical condition at the present time, or have you been treated within the past year?

Yes No Not sure
If yes, please explain why:

Was your last medical checkup within the past year?

Yes No Not sure

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

Yes No
If yes, please explain why:

Are you taking any medications, non-prescription drugs, or herbal supplements of any kind?

Yes No
If yes, please list:

Do you suffer from any allergies (hay fever, latex/rubber, etc)?

Yes No Not sure
If yes, please list:

Have you ever had a peculiar or adverse reaction to any medicine or injections?

Yes No Not sure
If yes, please explain:

Do you or did you smoke?

Yes No
If yes, for how long?

Do you drink alcoholic beverages on a regular basis?

Yes No

Do you use recreational drugs? (e.g. cocain or amphetamines)

Yes No

(For women only) Are you pregnant?

Yes No
If yes, when is your due date?

Do you bruise easily or have prolonged bleeding?

Yes No

Have you ever fainted, had shortness of breath, or chest pains?

Yes No

Are you anxious during dental treatments? (Please indicate by marking the scale)

Not at all 1 2 3 4 5 Very anxious

If you are nervous, would you like us to consider additional techniques along with "freezing" to help you?

Yes No

Have you ever had any serious trouble with any previous dental treatment?

Yes No
If yes, please describe:

Are there any conditions or diseases you have had not listed above?

Yes No Not sure

Is there anything else we should know about your health?

CONSENT

I, undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize Smiles Dental Aurora dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care, I also understand that responsibility for payment for the dental services provided for myself and my dependants is mine and I will assume responsibility for fees associated with these services.

Patient Name*:

Date*:

Initials*:

Patient Guardian Parent

15213 Yonge St, Suite 6
Aurora, ON
L4G 1L8

905-727-6453
reception@smiledental.ca

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Medical History Form

PATIENT INFORMATION

In case of emergency, we should notify:

CONSENT

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