We Accept The Canadian Dental Care Plan (CDCP). Schedule Your Appointment Today!
Facebook-f Instagram
(403) 294-1077
Book Online

Medical History

Patient's Legal Name:(Required)
Date of Birth:(Required)
What is your estimate of your general health?

1. hospitalization for illness or injury
2. an allergic reaction to
3. heart problems, or cardiac stent within the last six months
4. history of infective endocarditis
5. artificial heart valves, repaired heart defect (PFO)
6. pacemaker or implantable defibrillator
7. orthopedic implant (joint replacement)
8. rheumatic or scarlet fever
9. high or low blood pressure
10. a stroke (taking blood thinners)
11. anemia or other blood disorder
12. prolonged bleeding due to a slight cut (INR>3.5)
13. emphysema, shortness of breath, sarcoidosis
14. tuberculosis, measles, chicken pox
15. asthma
16. breathing or sleep disorders (i.e. sleep apnea, snoring, sinus)
17. kidney disease
18. liver disease
19. jaundice
20. thyroid, parathyroid disease, or calcium deficiency
21. hormone deficiency
22. high cholesterol or taking statin drugs
23. diabetes
24. stomach or duodenal ulcer
25. digestive problems (i.e. celiac disease, gastric reflux)
26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
27. arthritis
28. autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)
29. glaucoma
30. contact lenses
31. head or neck injuries
32. epilepsy, convulsions (seizures)
33. neurologic disorders (ADD/ADHD, prion disease)
34. viral infections and cold sores
35. any lumps or swelling in the mouth
36. hives, skin rash, hay fever
37. STI/ STD/ HPV
38. hepatitis
39. HIV/ AIDS
40. tumor, abnormal growth
41. radiation therapy
42. chemotherapy, immunosuppressive medication
43. emotional difficulties
44. psychiatric treatment
45. antidepressant medication
46. alcohol / recreational drug use

ARE YOU:

47. presently being treated for any other illness
48. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
49. taking medication for weight management
50. taking dietary supplements
51. often exhausted of fatigued
52. experiencing frequent headaches
53. a smoker, smoked previously or use smokeless tobacco
54. considered a touchy / sensitive person
55. often unhappy and depressed
56. taking birth control pills
57. currently pregnant
58. prostate disorders

List all medications, supplements, and or vitamins taken within the last two years.
Drug
Purpose
 
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.