Existing Patient Medical History Update FormExisting Patient Medical History Update FormStep 1 of 250%Patient Name* First Last Nickname/Preferred Name:Gender Male Female OtherDate Of Birth:* Year Month Day Primary Phone Number:*This is a:* Home Phone Cell PhonePlease Note: Our office uses text message reminders that can only be sent to cell phones. If you do not use a cell phone, we can send reminders via email.Secondary Phone Number:This Is A: Home Phone Cell PhoneEmail Address:* Home Address / Mailing Address:* Street Address Address Line 2 City Province ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Name of Physician(s) and their Specialty: Doctor's Name Specialty Doctor's Name Specialty Doctor's Name Specialty What is your estimate of your general health?* Excellent Good Fair PoorHave you ever been hospitalized for an illness or injury?* Yes NoIf yes, reason for hospitalization, estimated date, and any complications experienced:Have you ever had an allergic or bad reaction to the following (please check):Aspirin AspirinType of reaction that occurred? Approximate date of reaction?NSAIDs (e.g. Ibuprofen, Naproxen) NSAIDs (e.g. Ibuprofen, Naproxen)Type of reaction that occurred? Approximate date of reaction?Acetaminophen (i.e. Tylenol) Acetaminophen (i.e. Tylenol)Type of reaction that occurred? Approximate date of reaction?Codeine CodeineType of reaction that occurred? Approximate date of reaction?Penicillin PenicillinType of reaction that occurred? Approximate date of reaction?Erythromycin ErythromycinType of reaction that occurred? Approximate date of reaction?Clindamycin ClindamycinType of reaction that occurred? Approximate date of reaction?Tetracycline TetracyclineType of reaction that occurred? Approximate date of reaction?Sulfa SulfaType of reaction that occurred? Approximate date of reaction?Local anesthetic Local anestheticType of reaction that occurred? Approximate date of reaction?Fluoride FluorideType of reaction that occurred? Approximate date of reaction?Chlorhexidine ChlorhexidineType of reaction that occurred? Approximate date of reaction?Metals (e.g. nickel) Metals (e.g. nickel)Type of reaction that occurred? Approximate date of reaction?Latex LatexType of reaction that occurred? Approximate date of reaction?Nuts NutsType of reaction that occurred? Approximate date of reaction?Fruit FruitType of reaction that occurred? Approximate date of reaction?Other OtherType of reaction that occurred? Approximate date of reaction?I have not had allergic/bad reactions I have not had allergic/bad reactionsDO YOU HAVE or HAVE YOU HAD (please check if applicable):Chest pain / angina Chest pain / anginaDate diagnosed? How often do you experience chest pain / angina? Any precipitating factors? Duration of pain? What relieves the pain (ie nitroglycerin)? Any specialist treating this condition?High blood pressure High blood pressureDate diagnosed? Current treatment? Which doctor is treating this condition?Low blood pressure Low blood pressureDate diagnosed? Current treatment? Which doctor is treating this condition?High cholesterol High cholesterolDate diagnosed? Current treatment? Which doctor is treating this condition?History of infective endocarditis History of infective endocarditisDate diagnosed? Do you see a specialist and how often?Congenital heart defect (heart problem from birth) Congenital heart defect (heart problem from birth)Type and date diagnosed? Do you see a specialist and how often?Artificial heart valves or repair to valve Artificial heart valves or repair to valveDate of surgery? Do you see a specialist and how often?Heart attack / MI Heart attack / MIDate(s) diagnosed? Treatment (past or present)? Do you see a specialist and how often?Arrhythmia (e.g. irregular heart beat, atrial fibrillation) Arrhythmia (e.g. irregular heart beat, atrial fibrillation)Type and date diagnosed? Treatment (past or present)? Do you see a specialist and how often?Congestive heart failure Congestive heart failureDate diagnosed? Treatment (past or present)? Do you see a specialist and how often?Any heart conditions, heart surgery, or heart infections? Any heart conditions, heart surgery, or heart infections?What type of heart condition / infection do or did you have? Date diagnosed? What type of heart surgery did you have? Date of heart surgery and any complications experienced? Any specialist treating your condition(s)?Stroke (CVA) Stroke (CVA)Date(s) diagnosed? Any type of treatment (current or past)? Do you see a specialist and how often? Any residual effects?TIA (transient ischemic attack) TIA (transient ischemic attack)Date(s) diagnosed? Any type of treatment (current or past)? Do you see a specialist and how often? Any residual effects?Pacemaker PacemakerDate inserted? Type of pacemaker? Do you see a specialist and how often?Implanted defibrillator (ICD) Implanted defibrillator (ICD)Date inserted? Do you see a specialist and how often?Epilepsy / seizures Epilepsy / seizuresType? Date diagnosed? Treating doctor or specialist? Triggers? Frequency? Date of last episode? Any treatment (past or present)? Any hospitalizations?Asthma AsthmaDate diagnosed? Frequency of attacks? Severity of attacks (ie any hospitalizations)? Date of last attack? Triggers for the attacks (e.g. exercise, emotional upset, anxiety, stress)? Treatment (and how effective is the treatment)? Which doctor is treating this condition?Bronchitis BronchitisDate(s) diagnosed? Treatment received? Which doctor is treating this condition?Any breathing problems (COPD, Emphysema, Shortness of breath) Any breathing problems (COPD, Emphysema, Shortness of breath)Type? Date diagnosed? Treatment received? Which doctor is treating this condition?Sleep Apnea Sleep ApneaDate diagnosed? Treatment received? Which doctor is treating this condition?Diabetes DiabetesDate diagnosed? Type of diabetes (1 vs 2)? Treatment (e.g. diet/ exercise, oral medications, and/or insulin)? Presence of complications (e.g. neuropathy, cardiac disease)? Which doctor is treating this condition? Most recent hemoglobin A1c level? Most recent blood glucose (blood sugar) level (fasting or non fasting)?Hypothyroidism HypothyroidismDate of diagnosis? Current medication / any recent changes in dosage? Which doctor is treating this condition?Hyperthyroidism HyperthyroidismDate of diagnosis? Treatment (past or present)? Note: if radiation treatment was it radioactive iodine or external beam radiation? Current medication / any recent changes in dosage? Which doctor is treating this condition?Hormone deficiency or imbalance Hormone deficiency or imbalanceType? Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Acid reflux / GERD Acid reflux / GERDDate diagnosed? Treatment (past or present)? Which doctor is treating this condition?Stomach ulcerations Stomach ulcerationsDate diagnosed? Treatment (past or present)? Which doctor is treating this condition?Digestive disorder (e.g. Celiac disease) Digestive disorder (e.g. Celiac disease)Type? Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Liver problems (e.g. liver disease, cirrhosis, hepatitis) Liver problems (e.g. liver disease, cirrhosis, hepatitis)Type? Date diagnosed? Which doctor is treating this condition? Current status? Treatment (past or present)? Any known liver damage? Any known bleeding problems?Kidney disease Kidney diseaseType? Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Sexually transmitted disease (e.g. HPV) Sexually transmitted disease (e.g. HPV)Type? Date diagnosed? Which doctor is treating this condition?HIV / AIDS HIV / AIDSDate diagnosed? Last CD4 count? Viral load if known? Treatment (past or present)? Which doctor is treating this condition?Prosthetic joint Prosthetic jointWhich joint(s)? Month / year replaced? Any complications with the replacement (i.e. any infections)? Did the orthopedic surgeon recommend antibiotics before dental care?Arthritis (osteo or rheumatoid) Arthritis (osteo or rheumatoid)Type (osteoarthritis or rheumatoid)? Date diagnosed? Which joints affected? Treatment (past or present)? Which doctor is treating this condition?Osteopenia OsteopeniaDate diagnosed? Treatment (past or present)? Which doctor is treating this condition?Osteoporosis or ever taken antiresorptive medications (i.e. bisphosphonates) Osteoporosis or ever taken antiresorptive medications (i.e. bisphosphonates)Date diagnosed? Name of medication? Medication taken orally or intravenously? Dosage / frequency of medication? Which doctor is treating this condition?Head or neck injuries Head or neck injuriesType of injury and approximate date(s)? Treatment (past or present)?Neurologic disorders (e.g. Alzheimer’s disease, dementia) Neurologic disorders (e.g. Alzheimer’s disease, dementia)Type? Date diagnosed? Which doctor is treating this condition?Concentration problems or ADD/ADHD Concentration problems or ADD/ADHDDate diagnosed? Which doctor is treating this condition?Major depression Major depressionDate diagnosed? Treatment (past or present)? Which doctor is treating this condition?Anxiety disorders Anxiety disordersDate diagnosed? Treatment (past or present)? Which doctor is treating this condition?Bipolar disorder / schizophrenia / panic disorder / eating disorder Bipolar disorder / schizophrenia / panic disorder / eating disorderDiagnosis and date of diagnosis? Treatment (past or present)? Which doctor is treating this condition?Any bleeding problems Any bleeding problemsType of bleeding problem? Treatment (past or present)? Which doctor is treating this condition?Taking blood thinners Taking blood thinnersAnemia AnemiaDatę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Any problems with your immune system or take drugs that affect your immune system Any problems with your immune system or take drugs that affect your immune systemPlease provide more detail:Cancer CancerType of cancer? Date of diagnosis? Type / date of treatment, including when it finished? Follow up and future planned therapy? Current status of the disease? Which doctor is treating this disease?Chemotherapy ChemotherapyRadiation therapy Radiation therapyTaking steroids Taking steroidsReason for taking steroids?Tumour / abnormal growth Tumour / abnormal growthDiagnosis? Datę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Chronic ear infections Chronic ear infectionsTreatment (past or present)? Which doctor is treating this condition?Chronic sinus infections Chronic sinus infectionsTreatment (past or present)? Which doctor is treating this condition?Vertigo VertigoDatę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Alcohol Use Disorder Alcohol Use DisorderDatę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Drug Addiction (Substance Use Disorder) Drug Addiction (Substance Use Disorder)Datę diagnosed? Treatment (past or present)? Which doctor is treating this condition?I confirm I have not had any of the conditions to my knowledge I confirm I have not had any of the above conditions to my knowledgeARE YOU:Presently being treated for any other illness or medical condition (not listed above)? Presently being treated for any other illness or medical condition (not listed above)?Please provide more detail:Often exhausted or fatigued Often exhausted or fatiguedExperiencing frequent headaches or chronic pain Experiencing frequent headaches or chronic painPlease provide more detail:A smoker or vape user A smoker or vape userWhen did you start smoking / vaping? Approximately how often & how much do you smoke or vape?A previous smoker or vape user A previous smoker or vape userWhen did you start & stop smoking / vaping? Approximately how often & how much did you use to smoke or vape?Taking birth control Taking birth controlCurrently pregnant Currently pregnantWhat is your due date? Any complications experienced?Currently breastfeeding Currently breastfeedingI do not have any of the above conditions / they do not apply to me I do not have any of the above conditions / they do not apply to mePlease list any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment:Are you presently taking any medications, supplements, vitamins, and/or probiotics?* Yes NoList all medications, supplements, vitamins, and/or probiotics being taken (Include drug name, dosage, and purpose for taking it):Signature*CAPTCHANewsletter Subscribe to NewsletterPhoneThis field is for validation purposes and should be left unchanged.
