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Home
About Us
Doctors
Services
Children’s Dentistry
Cosmetic Dentistry
Crown and Bridge
Emergency Care
Functional Orthodontics
Invisalign
Oral Hygiene
Periodontics
Prosthetics
Root Canals
TMJ Therapy
Wisdom Teeth
Online Forms
Dental History Form
Health History Form
CDCP
Contact Us
Blog
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Office Information
Exploits Valley Dental Office
(709) 489-3660
4 Pinsent Drive
Grand Falls-Windsor, NF A2A 2R6
Patient Information
Patient Name
(Required)
First
Last
Home Phone
(Required)
Date
(Required)
MM slash DD slash YYYY
PID
Address 1
(Required)
Address 2
City and Province / State
(Required)
Postal / Zip Code
(Required)
Medical Alert
Condition
Premedication
Usual Dentist
Hygienist
Physician Visits
1. Have you visited a physician for a medical condition in the past two years?
(Required)
Yes
No
If yes, please explain.
Physician
Physician Phone
Physician Visit Dates
2. When was your last visit to a Physician?
MM slash DD slash YYYY
Last complete physical examination?
MM slash DD slash YYYY
Medications
3. Are you presently taking any PRESCRIPTION or NON-PRESCRIPTION drugs? Or have you recently taken any?
(Required)
Yes
No
If yes, please list.
Hospitalization
4. Have you been hospitalized in the past two years?
(Required)
Yes
No
Adverse Reactions / Medication Allergies
5. Have you ever reacted adversely to any of the following?
Antibiotics - Penicillin
Yes
No
Sulfonamide
Yes
No
Other antibiotics
Yes
No
Aspirin
Yes
No
Barbiturates (sleeping pills)
Yes
No
Codeine
Yes
No
Darvon
Yes
No
Local Anesthetic (freezing)
Yes
No
Nitrous oxide
Yes
No
Any other medication, please list.
Medication Restrictions
6. Have you ever been advised against taking any specific type of medication?
(Required)
Yes
No
If yes, please explain.
Allergic Conditions
7. Do you have any of the following?
Asthma
Yes
No
Hay Fever
Yes
No
Food Allergies
Yes
No
Metal or Latex Allergies
Yes
No
Skin Rashes
Yes
No
Hives
Yes
No
Any other allergic condition
Yes
No
If any other allergic condition, please explain.
General Health Questions
8. Has any family member had diabetes?
(Required)
Yes
No
9. Do you bleed EXCESSIVELY from a cut or injury, or bruise easily?
(Required)
Yes
No
10. Do your ankles, feet or hands swell?
(Required)
Yes
No
11. Has your weight, appetite or energy level changed dramatically recently?
(Required)
Yes
No
12. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?
(Required)
Yes
No
13. Do you follow a special diet?
(Required)
Yes
No
14. Have you recently tested HIV positive?
(Required)
Yes
No
15. Do you have FREQUENT SEVERE headaches, earaches, ear/throat infections?
(Required)
Yes
No
16. Have you ever had any injury or surgery to your face or jaws?
(Required)
Yes
No
17. Do you wear eyeglasses or contact lenses?
(Required)
Yes
No
18. Do you have any hearing difficulties?
(Required)
Yes
No
19. Do you smoke or use any other forms of tobacco?
(Required)
Yes
No
Are you wearing the transdermal nicotine patch?
Yes
No
20. Are you alcohol and/or drug dependent?
(Required)
Yes
No
Have you received treatment?
Yes
No
Medical Conditions Checklist
21. INDICATE WHICH OF THE FOLLOWING YOU PRESENTLY HAVE OR EVER HAD :
A.I.D.S.
Yes
No
Anemia
Yes
No
Angina pectoris
Yes
No
Arthritis / rheumatism
Yes
No
Artificial heart valve
Yes
No
Artificial joints (hip, knee)
Yes
No
Blood disorders
Yes
No
Bronchitis
Yes
No
Cancer
Yes
No
Circulation problems
Yes
No
Congenital heart lesions
Yes
No
Cortisone / steroid
Yes
No
Diabetes
Yes
No
Emphysema
Yes
No
Epilepsy or seizures
Yes
No
Fainting or dizzy spells
Yes
No
Glandular disorders
Yes
No
Glaucoma
Yes
No
Head / neck injuries
Yes
No
Heart disease or attack
Yes
No
Heart murmur
Yes
No
Heart pacemaker
Yes
No
Heart rhythm disorder
Yes
No
Heart surgery
Yes
No
Hepatitis A
Yes
No
Hepatitis B
Yes
No
Hepatitis C
Yes
No
Herpes
Yes
No
High / Low blood pressure
Yes
No
Hodgkins disease
Yes
No
Hyper (Hypo) Glycemia
Yes
No
Hypertension
Yes
No
Jaundice
Yes
No
Kidney disease
Yes
No
Liver disease
Yes
No
Lung disease
Yes
No
Malignant hyperthermia
Yes
No
Mental / nervous disorder
Yes
No
Mitral valve prolapse
Yes
No
Organ transplant / medical transplant
Yes
No
Psychiatric treatment
Yes
No
Radiation treatment / chemotherapy
Yes
No
Rheumatic / Scarlet fever
Yes
No
Sickle cell disease
Yes
No
Sinus trouble
Yes
No
Stomach / intestinal problems
Yes
No
Stroke
Yes
No
Thyroid disease
Yes
No
Tuberculosis
Yes
No
Ulcers
Yes
No
Venereal disease
Yes
No
Other
Yes
No
Other condition details
Child Patient History
22. Has the CHILD PATIENT recently had any of the following (indicate approximate date) :
Measles
Yes
No
Measles - approximate date
MM slash DD slash YYYY
Mumps
Yes
No
Mumps - approximate date
MM slash DD slash YYYY
Chicken Pox
Yes
No
Chicken Pox - approximate date
MM slash DD slash YYYY
Strep throat
Yes
No
Strep throat - approximate date
MM slash DD slash YYYY
Tonsillitis
Yes
No
Tonsillitis - approximate date
MM slash DD slash YYYY
Women Only
23. WOMEN ONLY: Are you pregnant or suspect you might be?
Yes
No
If yes, what is the expected birth date?
MM slash DD slash YYYY
Are you taking any birth control pills?
Yes
No
Additional Health Information
24. Do you currently have, or have you had in the past, any disease, condition, or problem not listed above?
(Required)
Yes
No
Please explain any disease, condition, or problem not listed above.
25. Is there anything else about your health we should be made aware of?
(Required)
Yes
No
Please provide details.
26. Do you wish to speak to the Doctor privately about any problem or medical condition?
(Required)
Yes
No
Signature
Guardian/Patient Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Δ
Appointment Request
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