Call Us for Further Info:

519-822-3888

Email Us :

info@guelphdentalcare.ca

5 Woodlawn Rd West, Suite 104 Guelph, Ontario N1H 1G8
Office Hours:

Mon - Fri: 10-7 | Sat: 9-5 | Sun: Closed

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Medical History
Medical History Questionnaire
Name
Name
First Name
Last Name
Address
Address
City
State/Province
Zip/Postal
Country

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

Name
Name
First Name
Last Name
Address
Address
City
State/Province
Zip/Postal
Country
Address
Address
City
State/Province
Zip/Postal
Country
1) Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain?
3)Has there been any change in your general health in the past year? If yes, please explain
4)Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list them
5) Do you have any allergies? If yes, please list them using the categories below:
6) Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain
7) Do you have or have you ever had asthma?
8) Do you have or have you ever had any heart or blood pressure problems?
9) Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i e infective endocarditis), a heart condition from birth (i e congenital heart disease) or a heart transplant?
10) Do you have a prosthetic or artificial joint?
11) Do you have any conditions or therapies that could affect your immune system (e g leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
12) Have you ever had hepatitis, jaundice or liver disease?
13) Do you have a bleeding problem or bleeding disorder?
14) Have you ever been hospitalized for any illnesses or operations? If yes, please explain
15) Do you have or have you ever had any of the following? Please check
16) Are there any conditions or diseases not listed above that you have or have had? If yes, please explain
17) Are there any diseases or medical problems that run in your family (e g diabetes, cancer or heart disease)?
18) Do you smoke or chew tobacco products?
19) Are you nervous during dental treatment?
20) Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?
21) Do you identify as a patient with a disability? If yes, please explain

To the best of my knowledge, the above information is correct:

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