smile365.ca - Medical History

Medical History
Patient’s Name: *

First Name Last Name
Birth Date *

Month Day Year
Date
Family Doctor
Dr’s Phone Number

Area Code Phone Number
Pharmacy
Pharmacy Phone Number

Area Code Phone Number
Do you have or ever had any of the following?
High Blood Pressure *

Yes No
Low Blood Pressure *

Yes No
Heart Disease: Atrial fib, Vent fib, CHF *

Yes No
What specific condition?
Congenital Heart Disease *

Yes No
Artificial Heart Valve, Unrepaired heart defect *

Yes No
History of Infective Endocarditis *

Yes No
Angina *

Yes No
Heart Surgery *

Yes No
What? *
When? *
Heart Attack *

Yes No
When? *
Stroke *

Yes No
When? *
Pacemaker, Implantable defibrillator *

Yes No
High Cholesterol *

Yes No
Anemia/Blood Disorder *

Yes No
What? *
Excessive Bleeding/ Blood Thinners

Yes No
INR?
Emphysema, C.O.P.D. *

Yes No
Tuberculosis *

Yes No
When? *
Asthma *

Yes No
*

Mild Moderate Severe
Hay Fever *

Yes No
*

Mild Moderate Severe
Sleep apnea *

Yes No
Mild Moderate Severe
CPAP Appliances
Kidney Disease *

Yes No
What specific condition? *
Liver Disease *

Yes No
What specific condition? *
Hepatitis *

Yes No
*

A B C Active/Carrier
Diabetes *

Yes No
Type I? Type II? Recent A1C? *
Acid Reflux Disease *

Yes No
Intestinal Problems, Stomach Ulcers, Celiac *

Yes No
What specific condition? *
Thyroid Problem *

Yes No
*

Hyper Hypo
Hormone Deficiency *

Yes No
Autoimmune Disorders: Fibromyalgia, Crohn’s, MS *

Yes No
What specific condition? *
Arthritis *

Yes No
*

Osteo Rheumatoid
Epilepsy/Convulsions *

Yes No
Type / Frequency *
Neurologic Problems : ADHD, Autism *

Yes No
What specific condition? *
Glaucoma *

Yes No
Cancer *

Yes No
Type *
When? *
Treatment *

Surgery Radiation Chemo
Joint Replacement: *

Yes No
*

Hip Knee
When? *
Viral infections, Cold Sores *

Yes No
What type? *
HIV/ AIDS *

Yes No
Osteoporosis, Osteopenia (Bisphosphonates) *

Yes No
Alcoholism, Drug dependency, Medical Marijuana *

Yes No
Birth Control Pill, , *

Yes No
Pregnant *

Yes No
Breastfeeding *

Yes No
Male: Prostate disorders *

Yes No
Are you allergic to or had a bad reaction to any of the following
Amoxicillin, Penicillin *

Yes No
Erythromycin *

Yes No
Clindamycin *

Yes No
Sulfa *

Yes No
Tetracycline, Doxycycline *

Yes No
Local Anaesthetic *

Yes No
Epinephrine *

Yes No
Chlorhexidine *

Yes No
Fluoride *

Yes No
Red Dye *

Yes No
Ibuprofen, Toradol, NSAIDS *

Yes No
Tylenol *

Yes No
Aspirin *

Yes No
Codeine, Morphine *

Yes No
Latex, Band-aids *

Yes No
Metals *

Yes No
What type of metal? *
Nuts *

Yes No
What type of Nuts *
Milk, Casein protein *

Yes No
Fruits *

Yes No
What? *
Other *

Yes No
Please list *
Are there any conditions or diseases not listed above that you currently have or had in the past? *

Yes No
If yes, please specify. *
Have you ever been hospitalized or had surgery? *

Yes No
If yes, please specify. *
Medication List
Are you taking any medication? *

Yes No
Please list all medications you are taking and the reason for taking them. ( Click on + to add more ) *
Patient Signature *

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Patient’s Name: *

First Name Last Name
Date *

Month Day Year
Date
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