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EMERGENCY CONTACT
NEW PATIENT
Services
Digital Dentistry
Dental Implants
Aesthetics
Comprehensive Care
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
Smile Consult
Meet Our Doctors
Dr. Paresh Shah
Dr. Neil Wilson
Meet Our Team
Contact
Medical History Form
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:
1. hospitalization for illness or injury
Yes
No
2. an allergic reaction to
aspirin, ibuprofen, acetaminophen, codeine
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
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
Submit
