Health Form

- must be completed in full**

Patient Information

Name (First & Last)

Middle Initial

Date of Birth

Height

Age

Weight (in kgs or lbs)

Gender

Male Female Other

Phone Number: Home

Cell

Other

Address

City

Prov

Postal Code

Supp Health

Yes No

NIHB

Yes No

Treaty #

Sask Health #

Emergency Contact

Name

Phone

Relationship

Dentist Name

Orthodontist Name (if applicable)

Physician Name

Referral Information

Who can we thank for the referral?

What is the reason for your visit to our practice?

Do you have anxiety about dental treatment?

Yes No

Health History

Are you in good physical health?

Yes No

Last physical exam

List of Surgeries

Last Hospitalization (also list reason)

Has there been any changes in your general health in the past year?

Yes No

If yes, please explain

Have you been under general anesthesia?

Yes No

Have you, or a family member, had any unusual or serious reactions to general anesthesia?

Yes No

If Yes, please explain

List all medications (prescription, non-prescription, herbal medication, etc)

For Osteoporosis/Osteopenia, are you taking Bisphosphonates?

Yes No

If so, last episode

If other medical condition, list here

Are you currently taking any of the following?

None

Blood Thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginkgo Biloba, Aggrenox, Pradaxa, Fish Oil, etc?)

Any natural product, herbal supplement or homeopathic remedy?

Diet Pills?

Steroid (eg. Prednisone)

Are you allergic to/or had any reaction to any of the following (if yes, list reaction):

Local Anesthetic (Numbing medication, Novocain, Lidocaine, etc)

Yes No

List reaction

Antibiotics

Yes No

List reaction

Medications

Yes No

List reaction

Latex

Yes No

List reaction

Soy

Yes No

List reaction

Eggs/Yolk

Yes No

List reaction

Other

Yes No

Specify and list reaction

Do you (or have you):

Smoking tobacco

Yes No

# of Years

How many/day?

Chewing tobacco

Yes No

Years and frequency

Vaping

Yes No

Years and frequency

Marijuana

Yes No

Years and frequency

Alcohol

Yes No

Frequency

History of alcohol abuse?

Yes No

Frequency

Use Illegal Drugs (cocaine, methamphetamine, etc)

Yes No

History of drug abuse?

Yes No

Women Only:

Are you pregnant?

Yes No

Trying to get pregnant?

Yes No

Menstrual Problems?

Yes No

Describe

Birth Control?

Yes No

I acknowledge the Saskatchewan Health Information Protection Act and I understand my rights of privacy with respect to my personal information.

I further consent to the collection, use and disclosure of my personal information for the following purposes:

To provide me with dental health service
Referral to another health professional or medical or dental specialist if required
To maintain communications and provide me with information and follow up respecting my dental care
To obtain payment of my account
For the uses and disclosures described in the privacy act

I have read and understand all of the above, and have filled out the above information to the best of my knowledge.

Name

Date

Signature (if under 18 – parent/guardian signature)

Your information will be encrypted.