Medical History

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Gender

Are you currently being treated for any medical condition or have you been treated within the past year?*

Has there been any change in your general health in the past year?*

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

Do you have any allergies?*

Have you ever had a peculiar or adverse reaction to any medicines or injections?*

Do you have or have you ever had asthma?*

Do you have or have you ever had any heart or blood pressure problems?*

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?*

Do you have a prosthetic or artificial joint?*

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

Have you ever had hepatitis, jaundice or liver disease?*

Have you ever been hospitalized for any illnesses or operations?*

Do you have or have you ever had any of the following? Please check all that apply.

Are there any conditions or diseases not listed above that you have or have had?

Do you smoke or use other nicotine products?

Are you breastfeeding or pregnant?

Do you identify as a patient with a disability?

General Release

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.*

Signature