Phone *
Date of Birth *
How did you hear about us? Referred by someone I know. Web search (ex. Google) other
Are you allergic to any Medication? Penicillin or codeine? No Yes
Please the medications you are allergic to
Have you ever been advised to take antibiotics prior to dental visit? No Yes
Do you have any other allergies? Latex? Food? No Yes
Have you ever taken a Bisposphonate medication such as Actonel (Risedronate), Aredia (Pamidronate), Bonefos (Clodronate), Boniva (Ibandronate), Didronel (Etidronate), Fosamax (Alendronate), or Zometa (Zoledronic Acid)? No Yes
Are you presently under the care of a doctor? No Yes
Have you been a patient in a hospital in the past 2 years? No Yes
Have you had general surgery? If so please indicate below when. No Yes
Please indicate the proximal date and type of surgery?
Have you ever had a lot of bleeding that needed special treatment? No Yes
Do you bruise easily? No Yes
Do you have any history of heart trouble? Angina? Heart attack? No Yes
Do you smoke, or chew tobacco? If so please indicate the frequency below. No Yes
Are you taking oral contraceptives or other hormones? No Yes
If applicable. Are you pregnant? If so please indicate your expected due date? No Yes
Medical History Details
Please list all medication and non-prescription drugs you are presently taking.
artificial joint replacement No Yes
cancer No Yes
confidential heart lesions No Yes
heart murmur No Yes
high blood pressure No Yes
stroke No Yes
glaucoma No Yes
tuberculosis No Yes
arthiritis No Yes
kidney trouble No Yes
anemia No Yes
jaundice No Yes
asthma No Yes
diabetes No Yes
epilepsy No Yes
scarlet or rheumatic fever No Yes
hepatitis A / B / C No Yes
pacemaker No Yes
infective endocarditis No Yes
HIV No Yes
thyroid trouble No Yes
respiratory problems No Yes
stomach ulcers No Yes
sinus trouble No Yes
drug/alcohol addiction No Yes
nerve disorders No Yes
hip, knee, TMJ replacement No Yes
prosthetic heart valve No Yes
bleeding disorder No Yes
Do you have any disease, condition or problem not listed that you feel we should know about? Please specify:
Do you have a fever or have felt hot or feverish anytime in the last two weeks? * No Yes
Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? * No Yes
Have you experienced a recent loss of smell or taste? * No Yes
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? * No Yes
Have you returned from travel outside of Canada in the last 14 days? * No Yes
Have you returned from travel within Canada from a location known affected with COVID-19? * No Yes
Are you over the age of 60? * No Yes
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder? * No Yes