Dr. Craig: Patient Self Medical History

Patient Self Medical History
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Sex *

M F
ID TYPE (OHIP, Driver's License, Passport) *
Please attach a picture of front of your ID *

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Cancel of
ID# *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you currently experiencing any pain or discomfort? *

Y N
Are you nervous about receiving dental treatment? *

Y N
Have you ever had a bad experience in a dental office? *

Y N
Have you been a patient in the hospital in the last 2 years? *

Y N
Have you been under the care of a doctor in the last 2 years? *

Y N
Are you on any medications? *

Y N
If yes, please list medications below:
Are you allergic to any medications? *

Y N
Have you ever had any excessive bleeding requiring special treatment? *

Y N
Do you become short of breath, tired, or have chest pain with exertion? *

Y N
Do your ankles swell during the day? *

Y N
Do you use more than 2 pillows to sleep? *

Y N
Do you ever wake from sleep short of breath? *

Y N
Have you lost or gained more than 10 lbs in the past year? *

Y N
Are you on a special diet? *

Y N
Please note if applicable
Heart Failure

Emphysema

HIV/Aids

Cancer

Heart Disease/Attack

Cough

HepatitisA

HepatitisB

Angina

Tuberculosis

Liver Disease

Hepatitis C

High Blood Pressure

Asthma

Jaundice

Artificial Joints

Heart Murmur

Hay Fever

Rheumatic Fever

Anemia

Congenital Heart Lesion

Sinus Trouble

Blood Transfusion

Jaw Joints Pain

Artificial Heart Valve

Sickle Cell Disease

Arthritis

Heart Pacemaker

Stroke Epilepsy/Seizures

Kidney Disease

Pregnancy

Heart Surgery

Gastric Ulcers

Diabetes

Thyroid Disease

Fainting/Dizziness

Glaucoma

Drug Addiction

Psychiatric Disorder

Recreational Drug Use
Do you have any disease, condition or problem listed above? *

Y N
If yes, please specify
To the best of my knowledge, all of the preceding answers are true and correct. If there are any changes in my health/ medical conditions, I will notify the doctor immediately.
Date *

Month Day Year
Date
Signature *

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Should be Empty:

Patient Self Medical History

Please note if applicable

To the best of my knowledge, all of the preceding answers are true and correct. If there are any changes in my health/ medical conditions, I will notify the doctor immediately.