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(204) 837-4517

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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
     
     
     
     

    6-3421 Portage Ave.
    Winnipeg, MB R3K2C9

    204-837-4517

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