Baseline Dental Centre | Update Medical History

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

Address

Address Line 1

City

State

Zip Code

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?

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.

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

Update Medical History

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.

GENERAL RELEASE

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