Patient Medical Information Leave this field blank Patient Name Email Telephone Contact: Home Phone Mobile Phone Work Phone Medical Dr. Name Medical Dr. Phone Number Are you being treated for any medical conditions at the present time or have been treated within the last year? Yes No Not Sure If so, why? (optional) When was your last medical check-up? Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 Have there been any changes in your general health in the last year? Yes No Not Sure If yes, please explain (optional) Are you taking any medications, non-prescription drugs or herbal supplements of any kind? Yes No Not Sure If yes, please list (optional) Do you have any allergies? (If you answered yes, please list using the categories below) Yes No Not Sure Medications (optional) Latex/Rubber Products (optional) Other (e.g. Hayfever, Foods) (optional) Have you ever had an uncommon or adverse reaction to any medicines or injections? Yes No Not Sure If yes, please explain (optional) Do you have or have you ever had asthma? Yes No Not Sure Do you have or have you ever had any heart or blood pressure problems? Yes No Not Sure Do you have or have 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? Yes No Not Sure Have you ever had hepatitis, jaundice or liver disease? Yes No Not Sure If yes, which type of hepatitis? (optional) Do you have a prosthetic or an artificial joint? Yes No Not Sure If yes, please explain (optional) Do you have a bleeding problem or a bleeding disorder? Yes No Not Sure If yes, please explain (optional) Have you ever been hospitalized for any illness or operations? Yes No Not Sure If yes, please explain (optional) Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy Yes No Not Sure Do you have or have you ever had any of the following? Please checkmark each box that applies: (optional) AIDS Alzheimers Angina Anemia Arthritis Blood Transfusion Cancer Chest Pain Cold Sores Diabetes Type 1 Diabetes Type 2 Digestive Disorders Acid Reflux Drug / Alcohol Dependency Emphysema Epilepsy or Seizures Fibromyalgia Head / Neck Injury Heart Attack Heart Murmur High / Low Blood Pressure HIV Hodgkins Disease Hypo / Hyperglycemia Kidney Disease Lung Disease Lupus Migraine Mitral Valve Prolapse Osteoporosis Medications (e.g. Fosamax, Actonel) Pacemaker Parkinsons Disease Radiation / Chemotherapy Rheumatic Fever Infection-Sexually Transmitted Shortness of Breath Sleep Apnea Steroid Therapy Stomach Ulcers Stroke Thrush Thyroid Disorder TMJ Disorder Tuberculosis Are there any conditions or disease not listed above that you have or have had? Yes No Not Sure If yes, please list (optional) Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease) Yes No Not Sure If yes, please explain (optional) Do you smoke or chew tobacco products? Yes No Not Sure Are you nervous during dental treatment? Yes No Not Sure If yes, please explain (optional) Are you pregnant? Yes No Not Sure Do you have any oral habits? (e.g. thumb/finger sucking, teeth grinding, clenching, etc) Do you smoke cannabis? Dentist: Dr. Janet Lee Address: 3461 Dixie Rd. Unit 103Mississauga ON L4Y 3X4 Canada Tel: (905) 625-5751| (905) 602-0700 The information I have given above is true to the best of my knowledge Patient Signature Start drawing Clear Done Start over Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 PHIA permits us to collect and use your personal health information. In certain circumstances, PHIA also allows us to share it with others both inside and outside our organization. We do this for purposes such as: To provide you with health care; To get payment for your care which could include private insurers; To do health system planning and research; To report as required by law; Unless you tell us not to, we can share your personal health information with any health care provider who has, is or will be providing you with health care. Members of your health care team are only allowed access to the information they need to give you the care you need. If you tell us not to share your information with a health care provider, we will not share yourinformation unless permitted or required by law to do so. Please tell a member of your health care team if you do not want your information shared with a health care provider. Send
