The Dental Hauz

Medical History Form

8321 Kennedy Rd #22, Markham, ON L3R 5N4

(905) 470-4289

About you

In case of emergency, we should notify

Your doctors and insurance

Your health

Are you being treated for any medical condition at the present or have you been treated within the past year?
Has there been any change in your general health in the past year?
Do you have any allergies? If you answered yes, please list using the categories below: a) medications b) latex/rubber products c) other (e.g., hayfever, foods)
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
Have you ever had a peculiar or adverse reaction to any medications or injections?
Do you have or have you ever had any heart or blood pressure problems?
Do you have or have you ever had asthma?
Do you have or have you ever had an artificial 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?
Do you have a prosthetic or artificial joint?
Do you have any conditions or therapies that could affect your immune system, e.g., leukemia, AIDs, HIV infection, radiotherapy, chemotherapy?
Have you ever had hepatitis, jaundice or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illnesses or operations?
Do you have or have you ever had any of the following? Please check.
Are there any conditions or diseases not listed above that you have or have had?
Are there any diseases or medical problems that run in your family? (e.g., diabetes, cancer or heart disease)
For women only: Are you breastfeeding or pregnant?

Consent