Health History Form All fields marked with an asterisk (*) are required. Preferred Method of Contact*Home phoneMobile phoneWork phoneE-mail 1. Have you been under the care of a medical doctor during the past three years for a specific condition? YesNo 2. Please list medications and dosages taken presently or none* 3. Are you aware of an allergic (or adverse) reaction to any medication or substance? YesNo If yes, please list any allergies below: 4. Have you been a patient in the hospital in the past two years? YesNo If yes, please list any procedure(s) below: Indicate which of the following you have had, or have at present. Heart (Surgery, Disease, Attack)YesNoHigh Blood PressureYesNoChest PainYesNoArtificial Heart ValveYesNoStrokeYesNoThyroid ProblemsYesNoLiver DiseaseYesNoHepatitis A, B or CYesNoArtificial Joint antibiotic prophylaxisYesNoOsteoporosisYesNoSickle Cell DiseaseYesNoEmphysemaYesNoH.I.V. PositiveYesNoSleep ApneaYesNoDo you wear a CPAP at night?YesNo CancerYesNoIf yes to cancer, which type? Radiation TherapyYesNoChemotherapyYesNo DiabetesYesNoIf yes to diabetes, what is Blood sugar? mmol Heart Murmur requiring antibiotic prophylaxisYesNoRheumatic FeverYesNoPsychiatric/psychological careYesNoDepressionYesNoNeurological DisordersYesNoEpilepsy or SeizuresYesNoKidney DiseaseYesNoGlaucomaYesNoArthritisYesNoHemophiliaYesNoCortisone MedicineYesNoAsthmaYesNoA.I.D.S.YesNo Please list any diseases, condition or problem not listed above: Smoking/Vaping Do you smoke or use e-cigarettes (vape)YesNoIf yes, If you quit smoking, when? How much did you smoke and for how long? Women Pregnant?—Please choose an option—YesNo If yes, how many months? Nursing?—Please choose an option—YesNoTaking birth control pill?—Please choose an option—YesNoAre you or have you been through menopause?—Please choose an option—YesNo Dental Information Do you: Have dental pain or problems now?YesNoFear the dentist or dental treatment?YesNoGrind or clench your teeth?YesNoHave pain on opening/closing?YesNoHave bleeding gums?YesNoHave dental implants?YesNo Have you: Had problems with dental anaesthetic?YesNoHad prolonged bleeding after extraction?YesNoNoticed shifting of your teeth?YesNoEver been told you have gum disease?YesNoEver had gum surgery?YesNo How often to you brush your teeth per day?* How often to you floss your teeth per day?* Do you have any other dental condition Dr. Sharma should be aware of? Date of most recent dental cleaning*: Scheduling We reserve appointment times for you specifically and do our very best to be on schedule. We require 48 business hours notice for cancellation or change or appointment. Changes or cancellations with less notice than 48 business hours are subject to a $100 fee. Insurance Please remember that your insurance plan is an agreement between yourself and your insurance company. Most plans do not cover all costs of care, particularly specialty services. We are happy to complete forms for your insurance company, however the patient or guardian is responsible for all fees incurred and they are due at the time service is provided. Please turn off your cell phone and pagers so that we might have your uninterrupted attention during your visit. Signature: Press the button below to submit the completed health history form.
