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Medical history form

Your health conditions, allergies and medicines, so we can treat you safely. It takes about 10 minutes.

Lilac Family Dentistry · 4430 Bathurst St, Suite 509, North York, ON M3H 3S3 · 416-638-1374

The information in this questionnaire is confidential and helps our office provide the highest level of care and service possible. Please complete all questions as completely as you can. Thank you.

1Patient

Address

2Family doctor

What is your estimate of your general health?

3Allergies

Do you have or have you ever had an allergic or bad reaction to any of the following:

Aspirin, ibuprofen, acetaminophen, codeine
Penicillin
Erythromycin
Tetracycline
Sulfa
Local anesthetic
Fluoride
Sulpha
Chlorhexidine (CHX)
Metals (nickel, gold, silver, etc.)
Fruit
Other

4Medical history

Do you have or have you ever had:

Hospitalization for illness or injury
Heart problems, or cardiac stent within the last six months
History of infective endocarditis
Artificial heart valve, repaired heart defect (PFO)
Pacemaker or implantable defibrillator
Orthopedic or soft tissue implant (e.g. joint replacement, breast implant)
Heart murmur, rheumatic or scarlet fever
High or low blood pressure
A stroke (taking blood thinners)
Anemia or other blood disorder
Prolonged bleeding due to a slight cut (or INR > 3.5)
Pneumonia, emphysema, shortness of breath, sarcoidosis
Chronic ear infections, tuberculosis, measles, chicken pox
Breathing problems (e.g. asthma, stuffy nose, sinus congestion)
Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)
Kidney disease
Liver disease or jaundice
Vertigo (e.g. “the room is spinning”)
Thyroid, parathyroid disease, or calcium deficiency
Hormone deficiency or imbalance (e.g. polycystic ovarian syndrome)
High cholesterol or taking statin drugs
Diabetes
Stomach or duodenal ulcer
Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
Osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)
Arthritis or gout
Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)
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/HPV
Hepatitis A
Hepatitis B
Hepatitis C
HIV/AIDS
Tumor, abnormal growth
Radiation therapy
Chemotherapy, immunosuppressive medication
Emotional difficulties
Psychiatric treatment or antidepressant medication
Concentration problems or ADD/ADHD diagnosis
Alcohol/recreational drug use

5Current health

Are you:

Presently being treated for any other illness
Aware of a change in your health in the last 24 hours (e.g. fever, chills, new cough, or diarrhea)
Taking medication for weight management
Taking dietary supplements
Often exhausted or fatigued
Experiencing frequent headaches or chronic pain
A smoker, smoked previously or other (smokeless tobacco, vaping, e-cigarettes, and cannabis)
Considered a touchy/sensitive person
Often unhappy or depressed
Taking birth control pills
Currently pregnant
Diagnosed with a prostate disorder

6Treatment and medicines

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

Please advise us in the future of any change in your medical history or any medications you may be taking.

7Signature

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Need help with a form? Our team speaks English, Farsi, Russian and Ukrainian. Call 416-638-1374, or fill in a paper copy at the office (please arrive 15 to 30 minutes early).