Aberfoyle Dental

Medical History

Medical History Questionnaire

Medical Alert

Title*

Name*

Date of Birth

Email*

Referred By

Home or Mobile Phone*

Home Address*

In Case Of Emergency, We Should Notify:

Emergency Contact

Emergency Phone

Name of Family Doctor

Doctor Phone/Address

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

1. Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain:

2. When was your last medical checkup?

3. Has there been any change in your general health in the past year? If yes, please explain:

4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please explain:

5. Do you have any allergies? If yes, please name them:

6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain:

7. Have you ever been hospitalized for any illnesses or operations? If yes, please explain:

8. Do you have or have you ever had any of the following? Please check;

9. Are there any conditions or diseases not listed above that you have or have had? If yes, please explain:

10. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?

11. Do you smoke or chew tobacco products? Do you use recreational drugs? If yes, please name them:

12. Are you nervous during dental treatment?

13. Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?

14. Do you identify as a patient with a disability? If yes, please explain:

I confirm that I am not presenting any of the following symptoms of COVID 19 Identified by Ontario Health Services: Fever above 38 C ,Cough, flue like symptoms, difficulty breathing, sore throat, loss of taste or smell, nausea/ vomiting , diarrhea.

I confirm that I am not currently positive for the novel coronavirus and not waiting for the results of a laboratory test for the novel coronavirus.

I verify that I have not returned to Ontario from any country outside of Canada whether by car, air, bus or train in the past 14 days.

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Ontario Health, the Communicable Disease Control or any other governmental health agency.

I verify the information above is correct to the best of my knowledge

Date *

Get in Touch!

Welcome to call us for appointments or questions.

ContactUs!

Get in Touch!

Welcome to call us for appointments or questions.

ContactUs!