Medical History Form | Canyon Dental Centre

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(403) 225-1991

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Welcome to Canyon Dental Centre

"*" indicates required fields

PROFILE

Name*

First Last

Phone*

Age*

Name of physician*

Most recent physical examination

What is your estimate of your general health?

Excellent

Good

Fair

Poor

DO YOU HAVE or HAVE YOU EVER HAD:

Hospitalization for illness or injury*

YES

NO

Please add further details

An allergic or bad reaction to any of the following:

aspirin, ibuprofen, acetaminophen, codeine

penicillin

erythromycin

tetracycline

sulfa

local anesthetic

fluoride

metals (nickel, gold, silver)

latex

nuts

fruit

other

Heart problems, or cardiac stent within the last six months*

YES

NO

Please add further details

History of infective endocarditis*

YES

NO

Please add further details

Artificial heart valve, repaired heart defect (PFO)*

YES

NO

Please add further details

Pacemaker or implantable defibrillator*

YES

NO

Please add further details

Orthopedic implant (joint replacement)*

YES

NO

Please add further details

Rheumatic or scarlet fever*

YES

NO

Please add further details

High or low blood pressure*

YES

NO

Please add further details

A stroke (taking blood thinners)*

YES

NO

Please add further details

Anemia or other blood disorder*

YES

NO

Please add further details

Prolonged bleeding due to a slight cut (INR > 3.5)*

YES

NO

Please add further details

Pneumonia, emphysema, shortness of breath, sarcoidosis*

YES

NO

Please add further details

Tuberculosis, measles, chicken pox*

YES

NO

Please add further details

Asthma*

YES

NO

Please add further details

Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)*

YES

NO

Please add further details

Kidney disease*

YES

NO

Please add further details

Liver disease*

YES

NO

Please add further details

Jaundice*

YES

NO

Please add further details

Thyroid, parathyroid disease, or calcium deficiency*

YES

NO

Please add further details

Hormone deficiency*

YES

NO

Please add further details

High cholesterol or taking statin drugs*

YES

NO

Please add further details

Diabetes*

YES

NO

Type

HbA1c =

Stomach or duodenal ulcer*

YES

NO

Please add further details

Digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)*

YES

NO

Please add further details

Osteoporosis/osteopenia (i.e. taking bisphosphonates)*

YES

NO

Please add further details

Arthritis*

YES

NO

Please add further details

Autoimmune disease*

(i.e. rheumatoid arthritis, lupus, scleroderma)

YES

NO

Please add further details

Glaucoma*

YES

NO

Please add further details

Contact lenses*

YES

NO

Please add further details

Head or neck injuries*

YES

NO

Please add further details

Epilepsy, convulsions*

(seizures)

YES

NO

Please add further details

Neurologic disorders*

(ADD/ADHD, prion disease)

YES

NO

Please add further details

Viral infections and cold sores*

YES

NO

Please add further details

Any lumps or swelling in the mouth*

YES

NO

Please add further details

Hives, skin rash, hay fever*

YES

NO

Please add further details

STI/STD/HPV*

YES

NO

Please add further details

Hepatitis*

YES

NO

Please add further details

HIV/AIDS*

YES

NO

Please add further details

Tumor, abnormal growth*

YES

NO

Please add further details

Radiation therapy*

YES

NO

Please add further details

Chemotherapy, immunosuppressive medication*

YES

NO

Please add further details

Emotional difficulties*

YES

NO

Please add further details

Psychiatric treatment*

YES

NO

Please add further details

Antidepressant medication*

YES

NO

Please add further details

Alcohol/recreational drug use*

YES

NO

Please add further details

ARE YOU:

Presently being treated for any other illness*

YES

NO

Please add further details

Aware of a change in your health in the last 24 hours*

(i.e. fever, chills, new cough, or diarrhea)

YES

NO

Please add further details

Taking medication for weight management*

YES

NO

Please add further details

Taking dietary supplements*

YES

NO

Please add further details

Often exhausted or fatigued*

YES

NO

Please add further details

Experiencing frequent headaches*

YES

NO

Please add further details

A smoker, smoked previously or use smokeless tobacco*

YES

NO

Please add further details

Considered a touchy/sensitive person*

YES

NO

Please add further details

Often unhappy or depressed*

YES

NO

Please add further details

Taking birth control pills*

YES

NO

Please add further details

Currently pregnant*

YES

NO

Please add further details

Diagnosed with a prostate disorder*

YES

NO

Please add further details

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment.

(i.e. Botox, Collagen Injections)

MEDICATION, SUPPLEMENTS, VITAMINS

List all medications, supplements, and or vitamins taken within the last two years.

Drug

Purpose

Click the + icon on the right to add more rows.

Patient’s Signature

From all of us at Canyon Dental Centre, we look forward to seeing you soon.

We look forward to hearing from you soon!
Call us at (403) 225-1991 to book an appointment!

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Southcentre Mall
Suite 121 - Anderson Road
Calgary AB, T21 3V1

Contact Us

(403) 225-1991

Monday 7:30 am to 4:00 pm

Tuesday 7:30 am to 7:00 pm

Wednesday 7:30 am to 7:00 pm

Thursday 7:30 am to 7:00 pm

Friday 8:30 am to 4:00 pm

Saturday 9:00 am to 3:00 pm

Sundays Closed

Statutory Holidays Closed

Disclaimer

The dentists at Canyon Dental are all General Dentists. As general dentists, they provide cosmetic dental procedures such as porcelain veneers, dental crowns, dental braces, and teeth whitening as part of their General Dentistry license. Cosmetic Dentistry & Family Dentistry are not specialties recognized by the Alberta Dental Association & College of Dental Surgeons of Alberta (CDSA). As South Calgary Family Dentists, they provide General Dental procedures for all ages within the family.

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Why Choose Us
Services
New Patients
- New Patient Form
Team
Appointments
Education
Products
Contact

Welcome to Canyon Dental Centre

PROFILE

DO YOU HAVE or HAVE YOU EVER HAD:

ARE YOU:

MEDICATION, SUPPLEMENTS, VITAMINS

From all of us at Canyon Dental Centre, we look forward to seeing you soon.

We look forward to hearing from you soon! Call us at (403) 225-1991 to book an appointment!

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Disclaimer

We look forward to hearing from you soon!
Call us at (403) 225-1991 to book an appointment!