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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:
*
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Exams and Hygiene
Emergency Dental Care
General Checkups
Children’s Dental Hygiene
Cosmetic Dentistry
Veneers
Whitening
Invisalign®
Restorative Services
Crowns
Bridges
Fillings
Implant Dentistry
Partial Dentures
Dentures
Root Canal Therapy
Oral Surgery
Nitrous Oxide Sedation
Oral Sedation
Wisdom Teeth
Extractions
Oral Appliances
Snoring & Sleep Apnea Solutions
Sports Guard
Technology
Velscope Screening
Laser Therapy
