Medical History Form Medical History "*" indicates required fields Name First Last Are you currently in good health?* Yes No (if no please explain) Please explain your health conditions:*Are you currently taking any medications or vitamins (prescription, over-the-counter, recreational)?* Yes (if yes please list medications) No Please list your medications:*Do you currently smoke?* Yes No Are you allergic to or ever had a reaction to any of the following: Penicillin Codeine Local Anesthetic (“freezing") Aspirin (ASA) Sulfa Drugs Other Please explain your other allergies:*Are you under the regular care of a physician?* Yes No Do you bleed more or longer than normal after a cut, bruise, surgery or previous tooth removal?* Yes No Have you ever had a serious illness or operation?* Yes No Women: are you pregnant?* Yes No Is there anything else we should know about your health?* Yes No Please specify other health issues:*Do you currently have or ever had any of the following conditions? Heart Trouble or Stroke Heart Murmur Thyroid Disorder Rheumatic Fever Breathing Problems Arthritis HIV Positive Tumours or Cancer High Blood Pressure Low Blood Pressure Hepatitis A / B / C Liver Disease Kidney Disease Mental Illness Diabetes Tuberculosis Epilepsy or Seizure Blood Disorders Hormonal Disorder Anxiety Other Please explain any other conditions:* Δ New Patients Welcome Take Care Of Your Oral Health & Book Your Dental Hygiene Appointment Today Request Appointment
