Health History Form

First Name*

Last Name*

Email Address *

Preferred Name

Date of Birth *

Age*

Marital Status -- Please select --MarriedUnmarried

Spouse's Name

Home Address*

City*

Province*

Postcode*

Country* CANADA

Home Phone Number*

Work Phone Number*

Cell Phone Number*

Occupation

Employer

Whom may we thank for referring you to our practice?

Physician's Name*

Physician's Phone Number*

Date of Last Visit?*

Alternative Healthcare Provider's Name (i.e. Naturopath, Osteopath, etc.)*

Allergies (i.e. drugs, metals, latex?)*

Prescription medications/dosage*

Supplements or over the counter medications*

Hospitalization or emergency care during the last 5 years? Reason?*

Have you ever been treated for the following? *

Do you smoketobacco?*YesNo

Do you smoke e-cigarettes?*YesNo

Do you smoke cannabis?*YesNo

Consume alcohol?*YesNo

Do you use recreational or street drugs?YesNo

Have you had a blood transfusion?*YesNo

Are you pregnant?*YesNo

Due Date

Are you nursing? YesNo

Do you use birth control prescriptions?YesNo

Previous Dentist

Reason for Leaving

How often do you visit the dentist?

Date of last visit

Date of Last X-rays

How often do you Brush/day

How often do you Floss/day

How often do you use Mouth Rinse/day

Are your teeth sensitive to Heat?*YesNo

Are your teeth sensitive to Cold?*YesNo

Are your teeth sensitive to Sweets?*YesNo

Are your teeth sensitive to Chewing Pressure?*YesNo

Have you ever had teeth removed?*YesNo

Haveyou had orthodontic treatment?*YesNo

Do you wear a retainer?*yesNo

Do your gums bleed with Brushing?*YesNo

Do your gums bleed with Flossing?*YesNo

Do you have bad Breath?*YesNo

Have your parents experienced gum disease or tooth loss?*YesNo

Do you have clicking, popping, or pain in your jaw?*YesNo

Do you clench/grind your teeth?*YesNo

Do you have Headaches?*YesNo

Do you have Jaw muscle stiffness in the morning?YesNo

Are you nervous or uneasy about having dental treatment?*YesNo

Are you satisfied with your smile?*YesNo

I am interested to learn about:*