Download Medical History Form

Medical History
Name:________________________________________
Birthdate:________________________________
1. What is your BC Care Card or personal health number? ____________________________________
2. Who is your family physician? _________________________________________________________
3. Do you have any major medical issues we should be aware of? Yes No
__________________________________________________________________________________
__________________________________________________________________________________
4. Have you been hospitalized for an overnight stay in the past 5 yrs? Yes No (if yes what for)
__________________________________________________________________________________
5. Have you been under the care of a medical doctor for a specific condition in the past 2 years? Yes No
(if yes what for) _____________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
6. Have you ever had a problem with excessive bleeding following medical or dental surgery? Yes No
__________________________________________________________________________________
__________________________________________________________________________________
7. Do you regularly take any prescription medications of any kind?
Medication Prescribed
_______________________
_______________________
_______________________
Yes No
(please list all)
Reason for Taking
________________________________________________________
________________________________________________________
________________________________________________________
8. Do you get shortness of breath when you lie down? Yes No
9. Are you allergic to Latex? Yes No
10. Do you have any allergies/sensitivities to medications or drug of any kind? _____________________
__________________________________________________________________________________
11. Do you have an artificial heart valve or a joint replacement like a hip or knee?
Yes No
(if yes what was the surgery date) ______________________________________________________
12. Have you been advised to take antibiotic pre-medication before every dental visit?
Yes No
(if yes for what reason)
__________________________________________________________________________
13. Are you taking, or have you ever taken bisphosphonate medication such as Actonel, Fosamax or
Zometa? Yes No (if yes for how long) _________________________________________________
WOMEN
14. Are you or might you be pregnant or nursing?
Yes No
15. Are you taking birth control medication?
Yes No
16. Are you anticipation pregnancy in the next 3 months? Yes No
Do you have a history of heart trouble? (Circle any that apply)
Angina Pectoris
Congenital Heart Lesions
Low Blood Pressure
Mitral Valve Prolapse-Regurgitation
Heart Attack
Heart Disease
Heart Failure
Heart Pacemaker
Heart Surgery
Heart Valve Problems
High Blood Pressure
Heart Murmur
General History (circle all that apply)
Anemia
Arthritis
Asthma
Bruise/Swell Easily
Cancer Treatment
Crohn's /Colitis
Diabetes Type I or II Epilepsy/Seizures
Hemophilia
Hepatitis A, B or C
Aids or HIV
Thyroid Problems
Kidney Disease
Liver Disease
Osteoporosis
Rheumatic Fever
Sinusitis
Tuberculosis
Ulcer
Signature of patient/guardian:____________________________________
Date:______________________