Your SW Calgary Family & General Dentist

Medical history

    MEDICAL HISTORY


    DO YOU HAVE or HAVE YOU EVER HAD:

    1. Hospitalization for illness or injury?YesNo

    2. An allergic or bad reaction to any of the following: YesNo



    3. Heart problems, or cardiac stent within the last six months?YesNo

    4. Artificial heart valve, repaired heart defect (PFO)?YesNo

    5. Pacemaker or implantable defibrillator? YesNo

    6. Orthopedic or soft tissue implant (e.g joint replacement, breast implant)? YesNo

    7. Heart murmur?YesNo

    8. Rheumatic or scarlet fever?YesNo

    9. High blood pressure?YesNo

    10. Low blood pressure?YesNo

    11. Stroke (taking blood thinners)?YesNo

    12. Anemia or other blood disorder? YesNo

    13. Kidney disease?YesNo

    14. Liver disease or jaundice? YesNo

    15. Thyroid, parathyroid disease, or calcium deficiency? YesNo

    16. Diabetes? (if yes which type) YesNo

    17. viral infections and cold sores YesNo

    18. Hepatitis? (if yes which type) YesNo

    19. HIV/AIDS? YesNo

    20. Radiation therapy, cancer, or chemotherapy? YesNo

    ARE YOU:

    21. Presently being treated for any other illness? YesNo

    22. A smoker?YesNo

    23. Taking birth control pills? YesNo

    24. Currently pregnant? YesNo

    25. Currently nursing? YesNo

    Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Collagen Injections)

    Drug & Purpose 1

    Drug & Purpose 2

    Drug & Purpose 3

    Drug & Purpose 4

    PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.