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601 Front Street, Nelson, B.C.
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Medical History Form
Patient Information
Patients First Name
*
Patients Last Name
*
Nickname / Pronunciation
Parent or Guardian
If patient is a child, please provide name of parent or guardian
Patient Birthdate
Month
Day
Year
Gender
Male
Female
Spouse's Name
Medical Information
How is your General Health
Excellent
Good
Fair
Poor
Family Doctor Name
Family Doctor Phone
Family Doctor Email
Date of Last Medical Exam
Month
Day
Year
History with Medical Specialists
Have you ever consulted any Medical Specialists? If yes, please list their name and phone number.
Orthopedic Surgeon
Phone Number
Oncologist
Phone Number
Cardiologist
Phone Number
Other
Phone Number
Known Medical Conditions or Issues (Past or Present)
Please select all that apply.
Heart Problems
Past
Present
KIdney Disease
Past
Present
Prolonged Bleeding
Past
Present
Repaired Heart Defect
Past
Present
Ulcers
Past
Present
Joint Replacement
Past
Present
Cardiac Stent
Past
Present
Hepatitis A B C
Past
Present
Cancer
Past
Present
High / Low Blood Pressure
Past
Present
Cold Sores
Past
Present
Radiation Treatment
Past
Present
Asthma / Difficulty Breathing
Past
Present
Artificial Heart Valve
Past
Present
Epilepsy / Convulsions
Past
Present
Diabetes (Controlled or Uncontrolled)
Past
Present
Pacemaker
Past
Present
GERD / Acid Reflux
Past
Present
Chemotherapy
Past
Present
Stroke
Past
Present
Eating Disorder
Past
Present
Prescription Drug Information
Please list any current medications, supplements, and vitamins.
Drug
Purpose
Drug
Purpose
Drug
Purpose
Drug
Purpose
Medication History
Do you have any allergies, or have you ever had any unusual reactions to the following?
Penicillin
Codeine
Local Anesthetic
Sulfa Drugs
Latex
Metals
Specific Antibiotics
Any other allergies? Please describe:
Have you ever been advised to take antibiotics prior to dental treatment?
Yes
No
Describe antibiotic recommendation:
Have you had any surgery in the last 2 years?
Yes
No
Describe Surgery
Do you take blood thinners or a baby (81mg) aspirin daily?
Yes
No
Do you take / have you taken any Bisphosphonate Drugs?
Yes
No
Smoking History
Do you use any of the following?
Cigarettes / Vapes
Cigars
Marijuana
How often?
For How Long?
Additional Information
Are there any serious medical conditions not mentioned? Describe:
Signature
I certify that the above information is true and complete to the best of my knowledge.
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