MEDICAL & PERSONAL UPDATE
YOUR PERSONAL CONTACT INFORMATION
Name
*
First Name
Middle Name
Last Name
Preferred Name
Gender you identify as
*
Male
Female
Other
Date of Birth:
*
-
Day
-
Month
Year
Date
Email
*
example@example.com
Main Contact Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
*
Home
Cell
Work
Secondary Contact Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Home
Cell
Work
Your Home Address:
*
Street Address
Unit/Suite #:
City
State / Province
Postal / Zip Code
OHIP # (Optional):
Driver’s License (Optional):
EMERGENCY CONTACT INFORMATION
Full Name:
*
First Name
Last Name
Contact Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Relationship:
*
MEDICAL CONTACT INFORMATION
Medical Office Name:
*
Medical Physician Full Name:
*
Telephone:
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Name:
Pharmacy Contact Number:
Please enter a valid phone number.
Format: (000) 000-0000.
I provide consent to Nobleton Dental Smiles to contact my medical physician for any medical information required to provide the care they require.
*
Yes
No
MEDICAL INFORMATION
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality
Your Last Medical Visit/Appointment:
*
-
Month
-
Day
Year
Date
Your Last Medical Appointment for a Comprehensive Physical:
*
-
Month
-
Day
Year
Date
Are you being treated for any medical condition:
*
Presently
In the Past Year
Your medical state has undergone any changes in the past year?
*
Yes
No
Please list any medications, non-prescription drugs or herbal supplements that you are taking:
Do you have any allergies to medications, latex, foods, or other?
*
Yes
No
Maybe/Not Sure
If yes, please explain:
Do you have or have had heart issues:
*
Infective endocarditis
Congenital heart disease
Heart transplant
Do you have any prosthetic or artificial joints?
*
Yes
No
If yes, please explain:
Do you have any immune system conditions?
*
Leukemia
Aids
HIV infection
Radiotherapy
Chemotherapy
None/Not Applicable
If yes, please explain:
Have you been hospitalized for any illness or operations?
*
Yes
No
If yes, please explain:
Do you smoke, vape, use e-cigarettes, or chew tobacco products?
*
Yes
No
If yes, please outline:
Daily
Weekly
Other
Do you have any disabilities we should be aware of
*
Yes
No
If yes, please explain:
If Applicable to your gender:
Are you pregnant?
Yes
No
If yes, how many months?
Breastfeeding:
Yes
No
MEDICAL REVIEW
Do you have any of the following conditions:
*
Asthma
Kidney disease
Eating Disorder
High Blood Pressure
Shortness of Breath
Mitral Valve Prolapse
Low Blood Pressure
Chest Pain. Angina
Thyroid Disease
Diabetes Stage?
Fainting/Dizzy Spells
Hepatitis A,B,C
Steroid Therapy
Osteoporosis Medications(e.g. Fosomax, Actonel)
Jaundice
Diabetes
Tuberculosis
Liver Disease
Lung Disease
Heart Attack
Bleed Disorder
Stomach Ulcers
Pacemaker
Arthritis/ Rheumatism
Drug/Alcohol Dependency
Heart Murmur
Seizures (Epilepsy)
Mental Health Concerns
Rheumatic Fever
Cancer
Stroke
None/NotApplicable
Are there any conditions you experience that is not listed above:
Please explain further if you checked off yes to any of the above
Please list any additional information that you think we should have to provide you the best possible care:
*
I confirm the above information is accurate
Patient Signature:
*
(Parent/Guardian if under the age of 16)
Today’s Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: