Patient Medical Information Patient Name Email Telephone Contact:HomeMobileWorkMedical Dr. Name Medical Dr. Phone NumberAre 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?When was your last medical check-up? MM slash DD slash YYYY Have there been any changes in your general health in the last year? Yes No Not Sure If yes, please explainAre you taking any medications, non-prescription drugs or herbal supplements of any kind? Yes No Not Sure If yes, please listDo you have any allergies? If you answered yes, please list using the categories below: Yes No Not Sure MedicationsLatex/Rubber ProductsOther (e.g. Hayfever, Foods)Have you ever had an uncommon or adverse reaction to any medicines or injections? Yes No Not Sure If yes, please explainDo you have or have you ever had asthma? Yes No Not Sure Type of pufferDo 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 Which type of hepatitis?Do you have a prosthetic or an artificial joint? Yes No Not Sure If yes, please explainDo you have a bleeding problem or a bleeding disorder? Yes No Not Sure If yes, please explainHave you ever been hospitalized for any illness or operations? Yes No Not Sure If yes, please explainDo 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 Check 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 ListAre there any diseases or medical problems that run in your family? Yes No Not Sure (e.g. diabetes, cancer or heart disease) Yes No Not Sure If yes, please explainDo you smoke or chew tobacco products? Yes No Not Sure Are you nervous during dental treatment? Yes No Not Sure If yes, please explainAre 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 103 Mississauga 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 SignatureDate MM slash DD slash YYYY 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.
