(613) 224-2332
booking@BaselineDentalCentre.com
1883 Baseline Rd.
Ottawa, Ontario K2C 0C7
Monday & Wednesday 8 A.M. - 5 P.M.
Tuesday & Thursday 8 A.M. - 8 P.M.
Friday 8 A.M. - 4 P.M.
Closed on Weekends
Home
About
Services
Contact
Forms
COVID-19 Screening Questionnaire
New Patient Form
Update Medical History
Book an appointment
Home
About
Services
Contact
Forms
COVID-19 Screening Questionnaire
New Patient Form
Update Medical History
Book an appointment
Baseline Dental Centre | Update Medical History
944
page-template-default,page,page-id-944,ajax_fade,page_not_loaded,,qode_grid_1300,footer_responsive_adv,qode-child-theme-ver-16.8.1550260007,qode-theme-ver-16.8,qode-theme-bridge,qode_header_in_grid,wpb-js-composer js-comp-ver-5.7,vc_responsive
Update Medical History
Please enable JavaScript in your browser to complete this form.
If you are a current patient, please ensure you update us on any changes to your health. The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality.
Patient Type
Adult
Child
Adult Under Guardianship
Email
*
Name of Guardian
*
First
Last
Self Identification
Man
Woman
Other
Non-Binary
Name of Patient
*
First
Last
Date of Birth
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Address
Address Line 1
City
State / Province / Region
British Columbia
Ontario
Quebec
Alberta
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Prince Edward Island
Saskatchewan
Yukon
Province
Code Postal
Home Phone
Cell Phone
Work Phone
Best Number to Reach you at?
Home
Cell
Work
Are you currently being treated for any medical condition or have you been treated within the past year?
Yes
No
When was your last medical checkup?
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Has there been any change in your general health in the past year?
Yes
No
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
Yes
No
Do you have any allergies?
Yes
No
Have you ever had a peculiar or adverse reaction to any medicines or injections?
Yes
No
Do you have or have you ever had asthma?
Yes
No
Do you have or have you ever had any heart or blood pressure problems?
Yes
No
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
Yes
No
Do you have a prosthetic or artificial joint?
Yes
No
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
Yes
No
Have you ever had hepatitis, jaundice or liver disease?
Yes
No
Have you ever been hospitalized for any illnesses or operations?
Yes
No
Do you have or have you ever had any of the following? Please check all that apply.
Chest pain, angina
Rheumatic fever
Steroid therapy
Seizures (epilepsy)
Heart attack
Mitral valve prolapse
Lung disease
Diabetes
Kidney disease
Stroke, TIA
Tuberculosis
Stomach ulcers
Thyroid disease
Shortness of breath
Heart murmur
Cancer
Arthritis
drug/alcohol/cannabis use or dependency
Osteoporosis medications (e.g. Fosamax, Actonel)
Loss of hearing
Difficulty hearing
Are there any conditions or diseases not listed above that you have or have had?
Yes
No
Do you smoke or use other nicotine products?
Yes
No
Are you breastfeeding or pregnant?
Yes
No
Do you identify as a patient with a disability?
Yes
No
GENERAL RELEASE
I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history to the best of my ability and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.
Signature..
Date
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Submit
Contact Us Today