Name
*
First Name
Last Name
Gender
*
Preferred Pronouns
*
Home Phone Number
(###)
###
####
Cellphone number
*
(###)
###
####
Email
*
Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
SK Health Number
*
Date of Birth
*
MM
DD
YYYY
Marital Status
*
Do you have a Treaty number?
*
Spouse / Parent / Guardian Name
*
Contact Number
*
(###)
###
####
Do you have dental insurance?
*
Pharmacy
*
1) General Health
*
2) Name of your Physician
*
3) Are you taking any medications at this time?
*
List all medications and the reason for taking it
5) Have your ever been treated for any of the following. Please indicate which one(s)
*
ADHD
Diabetes
Epilepsy
Heart Disease
Heart Murmur
Radiation
Congenital Heart Disease
High Blood Pressure
HIV
AIDS
Anxiety
Depression
Hepatitis A B C
Stroke
Thyroid Disorder
Tuberculosis
Ulcers
Rheumatic Fever
STI
Hay Fever
Arthritis
Bipolar
Schizophrenia
Other
4) Have you ever had any adverse effect to any of the following
6) Do you have or have you ever had asthma?
*
7) Do you have or have you ever had any heart or blood pressure problems?
*
8) Are you being treated for osteoporosis?
A. 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?
B. If yes, do you require a PRE MEDICATION before dental treatment?
10) Are you prone to fainting?
11) Have you been diagnosed with Sleep Apnea?
If yes, do you use CPAP?
12) A. Have you ever had cancer?
B. If yes, specify the following
13) Do you have a bleeding problem or bleeding disorder?
14) A. Do you have a prosthetic or artificial joint?
B. If yes, date of surgery?
Complications after surgery?
15) Do you have any conditions or therapies that could affect your immune system?
*
16) Have you ever had hepatitis, jaundice, or liver disease?
17) Have you ever been hospitalized for any illness or operations? If yes, please explain.
18) Do you have any disease, condition or problem not listed above?
*
19) Women, Are you pregnant?
How many weeks are you?
1) Have you ever had any injury to the face or jaw?
*
2) Do you clench, gnash or grind your teeth?
*
3) Do you have any problems chewing?
*
4) Do your gums bleed when
Patient (Parent / Guardian) Signature / Name
*
Provider Signature / Name
*
