Medical History

Medical History

Fill out the form below and we will contact you during our working hours.

    1. Are you in good health?

    2. When was the last time you had a medical examination?

    3. Are you presently receiving treatment for any illness? If yes, please provide details?

    4. Have you ever been hospitalized? If yes, please provide details?

    5. Do you have any heart or circulatory problems?

    6. Do you have a pacemaker?

    7. Have you ever had rheumatic fever? When?

    8. Have you ever been advised to take antibiotic pre-medication prior to dental treatment?

    9. Do you have seasonal/hay fever allergies?

    10. Do you have food allergies?

    11. Do you have medication allergies?

    12. Do you have other allergies?

    13. Are you presently taking any kind of medication? Please specify the drug and reason?

    14. Have you ever had a reaction to any kind of medicine or dental local anaesthetic?

    15. Female patients - Are you pregnant or think you may be pregnant?

    16. Female patients - Are you breastfeeding?

    17. Please indicate below if you PRESENTLY HAVE or HAVE EVER HAD ANY of the following?

    18. AIDS/HIV?

    19. Alcohol or chemical dependency?

    20. Arthritis or Rheumatism?

    21. Artificial jiots or valves?

    22. Asthma?

    23. Blood transfusion?

    24. Cancer/radiotherapy/chemotherapy?

    25. Diabetes?

    26. Eating disorders?

    27. Epilepsy/seizures?

    28. Fainting/dizzy spells?

    29. High/low blood pressure?

    30. Hyper/Hypo glycemia?

    31. Kidney disease?

    32. Liver disease (Hepatitis/Jaundice)?

    33. Lung disease/Chest pains?

    34. Mental or nervous disorder?

    35. Stomach ulcers?

    36. Stroke?

    37. Tuberculosis?

    38. Venereal/communicable disease?

    39. Do you smoke or vape? If yes, how much per day? How much per week?

    40. Do you grind or clench your teeth?

    41. Do you suffer from any of the following:

    42. Headaches?

    43. Earaches?

    44. Neck Aches?

    45. Is there any additional information related to your health that has not been addressed above?

    46. I, the undersigned, have completed the above questionnaire and/or update and that it is accurate to the best of my knowledge. I also certify that I consent to the performing of dental treatment and proceduresagreed to be necessary or advisable. I also agree to assume responsibility for fees associated with those procedures. I understand that during the course of treatment, unexpected difficulties may arise, resulting in an altered prognosis, or a change of proposed treatment. I also consent to the taking of diagnostic photographs or radiographs agreed to be necessary. I also consent to be contacted by email.?

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