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780-929-2929

5004-49 Ave, Beaumont AB, T4X 1E4

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Our Story
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Dental Implants

Cosmetic Dentistry

Airway & Sleep Solutions

Invisalign® Treatment

Wisdom Teeth Extractions

Teeth Whitening

Comprehensive Hygiene

Crowns and Bridges

Preventative Dentistry

Myofunctional Therapy

All Services

View All Services
Laser Dentistry
Airway & Sleep Solutions
Forms
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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?

General

Hospitalization for illness or injury

A smoker, smoked previously or use smokeless tobacco

Presently being treated for any other illness

Any lumps or swelling in the mouth

Head or neck injuries

Contact lenses

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

Taking dietary supplements

Alcohol/street drug use

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

Cardiovascular

History of infective endocarditis

Artifcial heart valve, repaired heart defect (PFO)

Heart problems, or cardiac stent within the last six months

Pacemaker or implantable defibrillator

A stroke (taking blood thinners)

High or low blood pressure

High cholesterol or taking statin drugs

Neurological

Neurologic disorders (ADD/ADHD, prion disease)

Emotional problems

Often unhappy or depressed

Antidepressant medication

Psychiatric treatment

Epilepsy, convulsions (seizures)

Experiencing frequent headaches

Immunological

Rheumatic or scarlet fever

Emphysema, shortness of breath, sarcoidosis

Arthritis, rheumatoid arthritis, lupus

Hives, skin rash, hay fever

Sleep

Breathing or sleep problems

Often exhausted or fatigued

Gastrointestinal

Stomach or duodenal ulcer

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

Hematological

Anemia or other blood disorder

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

Respiratory

Asthma

Emphysema, shortness of breath, sarcoidosis

Oncological

Tumor, abnormal growth

Chemotherapy, immunosuppressive

Radiation therapy

Other

Diabetes (HbA1c=_____)

Tuberculosis, measles, chicken pox

Liver disease, Hepatitis (type A, B, or C), Jaundice

Kidney disease

Thyroid, parathyroid disease, or calcium deficiency

Osteoporosis/osteopenia (i.e. taking bisphosphonates)

Glaucoma

HIV/AIDS, STI/STD

Artifcial prosthesis (heart valve or joints)

Hormone deficiency

Viral infections and cold sores

Male

Prostate disorders

Female

Pregnant

Taking birth control pills

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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Contact Us

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

Mon-Tues: 8am-4pm
Wed: 8am-7pm
Thurs: 8am-4pm
Fri: 7am-3pm
Sat: By Appointment Only
Sun: Closed

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