Medical History FormTitle MrMrsMissMsDr First Name * Last Name * Address *Street Address Apt, Suite, Bldg. (optional) *City *State / Province / Region Postal Zip Code Mobile Phone Number *After Hours Number Landline *Day Phone Email Emergency ContactEmergency Contact Name * Relationship Emergency Contact Phone Number * How did you hear about us? * Are you happy with the appearance of your teeth? YesNo Medical History - ConfidentialPast/Current medical conditionsAre you currently receiving any medical treatment? YesNo If Yes, please provide details Have you had any serious or long standing illness? YesNo If Yes, please provide details Have you ever been hospitalised? YesNo If Yes, please provide details Do you have, or have you suffered from:Rheumatic fever? YesNo Any heart complaint/treatment? YesNo Chronic Bronchitis or asthma? YesNo Hepatitis / HIV? YesNo Excessive bleeding? YesNo Have you ever had brain surgery? YesNo Joint replacements? YesNo Diabetes? YesNo Epilepsy? YesNo Thyroid disorder? YesNo High blood pressure? YesNo Radiation/Chemotherapy? YesNo If you answered YES to any of the questions, please supply more details here Other Medical InformationPlease inform us of any other conditions Are you pregnant? YesNo If yes, when is your due date? Do you smoke? YesNoSocial Do you wear sunscreen? YesNoOccasionally In the past 2 years have you undergone any operations? YesNo If Yes, Please provide more details Are you allergic to any medicine or tablets? YesNo If Yes, provide more details Please list any medication taken in the past year VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank
