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Elgin Dental & Hygiene Centre
Medical History Update
Contact Information:
Full Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Cell/Main Contact Number
*
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
Email
*
example@example.com
Medical History:
Are you under the care of a physician or have a family doctor:
*
Yes
No
Date of most recent exam:
-
Day
-
Month
Year
Date
Physician/Family Doctor Contact Information: (Please provide address and/or contact number.)
Have there been any changes to your health in the last 12 months?
*
Yes
No
If yes, please explain:
Have you been hospitalized in the last five years?
*
Yes
No
If yes, please describe reason and date:
Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken.
If list is extensive or unavailable, please let us know which pharmacy you use and we can get these details for you.
Please rate your overall health:
Are you pregnant?
*
Yes
No
Maybe
N/A
If yes many weeks are you into the pregancy?
*
N/A
Other
Are you breastfeeding?
*
Yes
No
N/A
Are you taking birth control?
*
Yes
No
N/A
Are you taking hormone replacement?
*
Yes
No
Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement?
*
Yes
No
If yes, include date, type of replacement and any complications.
Provide orthopedic surgeon's name and number.
Are you taking or planning to take an antiresorptive agent (such as Fosamax, Actonel, Boniva, Reclast, and Prolia)?
*
Yes
No
I'm not sure
If yes, what type, dosage and when was it taken?
Since 2001, have you or will you be treated with an antiresorptive agent (Aredia, Zometa, XGEVA)?
*
Yes
No
I'm not sure
If yes, for which conditon?
Bone pain
Multiple myeloma
Paget's disease
Metastatic cancer
Other
If yes, what type, dosage and when was it taken?
Are you allergic to or had a reaction to the following?
Latex
Codeine
Other Narcotics
Penicillin/Amoxicillin
Erythromycin
Tetracycline
Sulfa Drugs
Barbiturates
Local Anaesthetics
Metals
Hay Fever
Foods
Iodine
Animals
Pine nuts
Other
If yes to any please specify type and reaction.
Please indicate if you have or have had any of the following diseases or problems.
Cardiovascular disease
Congestive heart failure
Low blood pressure
High blood pressure
Mitral valve prolapse
Rheumatic heart disease
Blood transfusion
Arthritis
Systemic lupus erythematous
Emphysema
Chest pain upon exertion
Eating disorder
GI reflux/ Persistent heart burn
Angina
Heart attack
Pacemaker
Abnormal bleeding
Hemophilia
Autoimmune disease
Asthma
Sinus trouble
Chronic pain
Malnutrition
Ulcers
Artheriosclerosis
Heart murmur
Other congenital heart defect (CHD)
Rheumatic fever
Anemia
AIDS/HIV
Rheumatoid Arthritis
Bronchitis
Cancer/Chemotherapy/Radiation Therapy
Diabetes Type 1 (Insulin-Dependent) or Type 2 (Non Insulin-Dependent)
Gastrointestinal disease
Thyroid problem
Stroke
Epilepsy
Sleep disorder
Recurrent infection
Osteoporosis
Severe or rapid weight loss
Glaucoma
Fainting spells
Seizures
Snoring/Sleep apnea
Kidney problems/dyalisis
Persistent swollen glands in neck
Sexually transmitted disease
Damaged heart valves
Hepatitis
Jaundice
Neurological disorder
Mental heath disorder
Night sweats
Severe headaches/migraines
Herpes, cold sores, or feverish blisters
Other
If yes to any, list dates, kinds, controlled or uncontrolled
If yes to any of the following Congenital Heart Defect (CHD) conditions, antibiotic prophylaxis is recommended prior to all invasive dental treatments. Please consult your physician.
Artificial (prosthetic) valve
Previous infective endocarditis
Damaged valves in transplanted heart
CHD; unrepaired cyanotic CHD
CHD; repaired completely in last 6 months
CHD; repaired with residual defects
Has a physician or dentist recommended that you take antibiotics prior to dental treatment?
*
Yes
No
Do you have any diseases or problems not listed above that you think we should know about?
*
Yes
No
If yes, what information can you provide us?
Signature
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