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EMERGENCY CONTACT NEW PATIENT

Services
Lectures & Workshops
Smile Consult
Digital Smile Design
Meet Our Doctors
- Dr. Paresh Shah
- Dr. Neil Wilson
Meet Our Team
Contact

(204) 837-4517

Book Appointment

Call Today: (204) 837-4517

Book Appointment

Services

Digital Dentistry
Dental Implants
Aesthetics
Comprehensive Care

LECTURES & WORKSHOPS

Digital Smile Design

Meet Our Doctors

Dr. Paresh Shah
Dr. Neil Wilson

New Patient

Thank you for choosing Westwood Dental! Please download the forms below, fill them out, save it and send them to admin.westwood@mymts.net or you may print them out and bring them into the office during your visit. If you have any questions, please call our office at 204-837-4517.

MEDICAL HISTORY

Patient Name Nickname Age

Name of Physician/and their specialty

Most recent physical examination purpose

What is your estimate of your general health?

Excellent

Good

Fair

Poor

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

YES NO

1. hospitalization for illness or injury

Yes

No

2. an allergic reaction to

aspirin, ibuprofen, acetaminophen, codeine
penicillin
penicillin
tetracycline
sulpha
local anesthetic
fluoride
metals (nickel, gold, silver,
)
latex
other

3. heart problems, or cardiac stent within the last six months

Yes

No

4. history of infective endocarditis

Yes

No

5. artificial heart valve, repaired heart defect (PFO)

Yes

No

6. pacemaker or implantable defibrillator

Yes

No

7. artificial prosthesis (heart valve or joints)

Yes

No

8. rheumatic or scarlet fever

Yes

No

9. high or low blood pressure_

Yes

No

10. a stroke (taking blood thinners)

Yes

No

11. anemia or other blood disorder

Yes

No

12. prolonged bleeding due to a slight cut (INR > 3.5)

Yes

No

13. emphysema, sarcoidosis

Yes

No

14. tuberculosis

Yes

No

15. asthma

Yes

No

16. breathing or sleep problems (i.e. snoring, sinus)

Yes

No

17. kidney disease

Yes

No

18. liver disease

Yes

No

19. jaundice

Yes

No

20. thyroid, parathyroid disease, or calcium deficiency

Yes

No

21. hormone deficiency

Yes

No

22. high cholesterol or taking statin drugs

Yes

No

23. diabetes (HbA1c = )

Yes

No

24. stomach or duodenal ulcer

Yes

No

25. digestive disorders (i.e. gastric reflux)

Yes

No

YES NO

26. osteoporosis/osteopenia (i.e. taking bisphosphonates)

Yes

No

27. arthritis

Yes

No

28. glaucoma

Yes

No

29. contact lenses

Yes

No

30. head or neck injuries

Yes

No

31. epilepsy, convulsions (seizures

Yes

No

32. neurologic problems (attention deficit disorder)

Yes

No

33. viral infections and cold sores

Yes

No

34. any lumps or swelling in the mouth

Yes

No

35. hives, skin rash, hay fever

Yes

No

36. venereal disease

Yes

No

37. hepatitis (type )

Yes

No

38. HIV / AIDS

Yes

No

39. tumor, abnormal growth

Yes

No

40. radiation therapy

Yes

No

41. chemotherapy

Yes

No

42. emotional problems

Yes

No

43. psychiatric treatment

Yes

No

44. antidepressant medication

Yes

No

45. alcohol / drug dependency

Yes

No

WHAT IS YOUR IMMEDIATE CONCERN?

46. presently being treated for any other illness

Yes

No

47. aware of a change in your general health

Yes

No

48. taking medication for weight management (i.e. fen-phen)

Yes

No

49. taking dietary supplements

Yes

No

50. often exhausted or fatigued

Yes

No

51. subject to frequent headaches

Yes

No

52. a smoker or smoked previously

Yes

No

53. considered a touchy person

Yes

No

54. often unhappy or depressed

Yes

No

55. FEMALE - taking birth control pills

Yes

No

56. FEMALE - pregnant

Yes

No

57. MALE - prostate disorders

Yes

No

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.

List all medications, supplements, and or vitamins taken within the last two years

Drug

Purpose

Drug

Purpose

Ask for an additional sheet if you are taking more than 6 medications

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING

Patient’s Signature

Clear

OK

Date

Doctor’s Signature

Clear

OK

Date

6-3421 Portage Ave.
Winnipeg, MB R3K2C9

admin.westwood@mymts.net

© 2020. Dr. Paresh Shah