smile365.ca - Medical History

Medical History
Patient’s Name:*

First NameLast Name
Birth Date *

MonthDayYear
Date
Family Doctor
Dr’s Phone Number

Area CodePhone Number
Pharmacy
Pharmacy Phone Number

Area CodePhone Number
Do you have or ever had any of the following?
High Blood Pressure*

YesNo
Low Blood Pressure*

YesNo
Heart Disease: Atrial fib, Vent fib, CHF*

YesNo
What specific condition?
Congenital Heart Disease*

YesNo
Artificial Heart Valve, Unrepaired heart defect*

YesNo
History of Infective Endocarditis*

YesNo
Angina*

YesNo
Heart Surgery*

YesNo
What? *
When?*
Heart Attack*

YesNo
When? *
Stroke*

YesNo
When? *
Pacemaker, Implantable defibrillator*

YesNo
High Cholesterol*

YesNo
Anemia/Blood Disorder*

YesNo
What?*
Excessive Bleeding/ Blood Thinners

YesNo
INR?
Emphysema, C.O.P.D.*

YesNo
Tuberculosis*

YesNo
When? *
Asthma*

YesNo
MildModerateSevere
Hay Fever*

YesNo
MildModerateSevere
Sleep apnea*

YesNo
MildModerateSevere
CPAPAppliances
Kidney Disease*

YesNo
What specific condition?*
Liver Disease*

YesNo
What specific condition?*
Hepatitis*

YesNo
ABCActive/Carrier
Diabetes*

YesNo
Type I? Type II? Recent A1C?*
Acid Reflux Disease*

YesNo
Intestinal Problems, Stomach Ulcers, Celiac*

YesNo
What specific condition?*
Thyroid Problem*

YesNo
HyperHypo
Hormone Deficiency*

YesNo
Autoimmune Disorders: Fibromyalgia, Crohn’s, MS*

YesNo
What specific condition?*
Arthritis*

YesNo
OsteoRheumatoid
Epilepsy/Convulsions*

YesNo
Type / Frequency*
Neurologic Problems : ADHD, Autism*

YesNo
What specific condition?*
Glaucoma*

YesNo
Cancer*

YesNo
Type*
When?*
Treatment*

SurgeryRadiationChemo
Joint Replacement:*

YesNo
HipKnee
When?*
Viral infections, Cold Sores*

YesNo
What type?*
HIV/ AIDS*

YesNo
Osteoporosis, Osteopenia (Bisphosphonates)*

YesNo
Alcoholism, Drug dependency, Medical Marijuana*

YesNo
Birth Control Pill, ,*

YesNo
Pregnant*

YesNo
Breastfeeding*

YesNo
Male: Prostate disorders*

YesNo
Are you allergic to or had a bad reaction to any of the following
Amoxicillin, Penicillin*

YesNo
Erythromycin*

YesNo
Clindamycin*

YesNo
Sulfa*

YesNo
Tetracycline, Doxycycline*

YesNo
Local Anaesthetic*

YesNo
Epinephrine*

YesNo
Chlorhexidine*

YesNo
Fluoride*

YesNo
Red Dye*

YesNo
Ibuprofen, Toradol, NSAIDS*

YesNo
Tylenol*

YesNo
Aspirin*

YesNo
Codeine, Morphine*

YesNo
Latex, Band-aids*

YesNo
Metals*

YesNo
What type of metal?*
Nuts*

YesNo
What type of Nuts*
Milk, Casein protein*

YesNo
Fruits*

YesNo
What?*
Other*

YesNo
Please list*
Are there any conditions or diseases not listed above that you currently have or had in the past?*

YesNo
If yes, please specify. *
Have you ever been hospitalized or had surgery?*

YesNo
If yes, please specify. *
Medication List
Are you taking any medication?*

YesNo
Please list all medications you are taking and the reason for taking them. ( Click on + to add more )*
Patient Signature *

Clear
Patient’s Name:*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: