DOW Medical History Form

Dentistry On West
Patient's Full Name ( as it appears on your insurance card, if applicable*

First NameLast Name
Preferred Name
Address*

Street Address

City/ Province

CityProvince

Postal Code
Date of Birth

MonthDayYear
Phone Number
Gender*

MaleFemaleOther
Fill in the information from your Insurance card.

Insurance Company

Street Address Line 2

Group NumberCertificate Number

Postal / Zip Code

	Yes	No
Have you ever had any known contact with the AIDS virus?
Has any member of your family had diabetes ?
Do you bruise easily or bleed abnormally ?
Do your ankles swell duing the day?
Have you had any unusual weight changes recently?
Do you have any blood disorders such as anemia ( thin blood)?
Have you ever had any injury,surgery or xray therapy to your face or jaws?
Do you have frequent severe headaches?
Do you have frequent earaches, ear/throat infections or an hearing difficulties?
Are you on a special diet ?
Have you ever fainted ?
Have you had any organ transplants or medical inputs ?
Do you experience shortness of breath or pain in your chest when walking or climbing stairs?
Do you smoke or vape?

	Yes	No
Are you pregnant?
Are you taking any birth control pills?

Dentistry On West