bellevue dental group

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780-929-2929

5004-49 Ave, Beaumont AB, T4X 1E4

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Our Story
Services
Comprehensive Hygiene

Cosmetic Dentistry

Invisalign® Treatment

Emergency Dental

Botox

Wisdom Teeth Extractions

Teeth Whitening

Dental Implants

Crowns and Bridges

Infant Care

Preventative Dentistry

Myofunctional Therapy

All Services

View All Services
Solea®
Sleep Apnea
Forms
Contact Us

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Our Story
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Solea®
Sleep Apnea
Forms
Contact Us

Medical History Form

Patient's Full Name

Patient's Age

Date of Birth

MM slash DD slash YYYY

Name of Physician/and their specialty

Purpose of Your Visit

Most recent physical examination

MM slash DD slash YYYY

What is your estimate of your general health?

Excellent

Good

Fair

Poor

An allergic reaction to the following?

Aspirin, Ibuprofen, acetaminophen, codeine

Penicillin

Erythromycin

Tetracycline

Sulfa

Local anesthetic

Fluoride

Metals (nickel, gold, silver, etc)

Latex

Other:

Current Height

Please indicate either ft. or cm

Current Weight

Please indicate either lbs. or kg

Do you have or have you ever had any of the following?

Hospitalization for illness or injury

Heart problems, or cardiac stent within the last six months

History of infective endocarditis

Pacemaker or implantable defibrillator

Artifcial heart valve, repaired heart defect (PFO)

Rheumatic or scarlet fever

High or low blood pressure

A stroke (taking blood thinners)

Anemia or other blood disorder

Artifcial prosthesis (heart valve or joints)

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

Emphysema, shortness of breath, sarcoidosis

Tuberculosis, measles, chicken pox

Asthma

Breathing or sleep problems

Kidney disease

Liver disease

Jaundice

Thyroid, parathyroid disease, or calcium deficiency

Hormone deficiency

High cholesterol or taking statin drugs

Diabetes (HbA1c=_____)

Stomach or duodenal ulcer

Digestive disorders (i.e. celiac disease, gastric reflux)

Osteoporosis/osteopenia (i.e. taking bisphosphonates)

Arthritis, rheumatoid arthritis, lupus

Glaucoma

Contact lenses

Head or neck injuries

Epilepsy, convulsions (seizures)

Neurologic disorders (ADD/ADHD, prion disease)

Viral infections and cold sores

Any lumps or swelling in the mouth

Hives, skin rash, hay fever

STI/STD

Hepatitis (type____)

HIV/AIDS

Tumor, abnormal growth

Radiation therapy

Chemotherapy, immunosuppressive

Emotional problems

Psychiatric treatment

Antidepressant medication

Alcohol/street drug use

Presently being treated for any other illness

Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)

Taking medication for weight management (i.e. fen-phen)

Taking dietary supplements

Often exhausted or fatigued

Experiencing frequent headaches

A smoker, smoked previously or use smokeless tobacco

Often unhappy or depressed

FEMALE – taking birth control pills

FEMALE – pregnant

MALE – prostate disorders

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)

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

Signature

Today's Date

MM slash DD slash YYYY

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5004-49 Ave
Beaumont AB
T4X 1E4
780-929-2929

Hours

Mon-Thurs: 8am-4pm
Fri: 7am-3pm
Sat-Sun: Closed

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(780)-929-2929
5004 49 Ave, Beaumont, AB T4X 1E4
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