Medical History Surname Given Name First Given Name Middle Date of Birth MM slash DD slash YYYY Occupation Home phoneHome AddressWork PhoneMobile PhonePostal AddressEmail Address Health fund Member number Emergency Contact Guardian Contact How did you hear about us? Facebook Local Advertising Website Internet Word of Mouth If you were referred, may we have thier name so we can thank them? Doctor Name Doctor Phone Number Medical History Joint Replacemetn Arthritis Bisphospontate/Prolia Cancer Depression/Anxiety Epilepsy Excessive Bleeding/Blood Thinners Diabetes Hepatitis A,B or C Heart Disease Heart Murmur Kidney Disease Liver Disease HIV Radiation Therapy Lung Disease Sinus Problems Stroke Thyroid Disease Tuberculosis Rheumatic Fever Asthma High Blood Pressure Low Blood Pressure Autoimmune Disease Please check all that applyIf yes to Joint Replacement please supply the date of the most recent surgery If you have suffered from a major ilness in the last 5 years, or have other medical conditions not covered above, please elaborate. Please list all medications, natural or prescribed Do you have any allergies? Do you suffer from sleep apnea or snoring? please elaborate Are you a current smoker? If so how many in a day? Are you concerned about or experiencing any of the following dental problems? Hot/Cold Sensitivity Stained/Discolored Teeth? Bleeding Gums Head/Neck Ache Food Trapped in Teeth Discolored Fillings Bad Breath Griding/Clenching Jaw Clicking/Pain Broken or Rough Fillings Sensitivity When Eating Mouth Breathing Are you looking for information regarding Improving ability to eat Existing Crowns/Bridges Discolored Teeth Oral Hygeine Instruction Appearance of your Smile Previous Dental Treatment Crooked Teeth Silver/Mercury Fillings Cosmetic Procedures Missing Teeth/Implants Gaps In Teeth Tooth Whitening When was your last dental exam? MM slash DD slash YYYY Are you nervous about dental treatment?noa littleveryextremelyHave you recieved any of the following to allow dental treatment? Nitrous oxide (Laughing Gas) IV sedation General Anaesthesia Signature Date Signed MM slash DD slash YYYY