Choice Dental Group Health History

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Health History
Please complete the following form as accurately as possible. You will be required to update this form every year. However, if you have any medical changes, please notify us prior to your appointment.
Account ID*
Env*
Practice Name*
Email*
example@example.com
Patient Name*

First NameLast Name
If a minor, name of legal guardian / custodian
Birthdate*

MonthDayYear
Sex/Gender?*

FemaleMaleOther
Alberta Health Care No.
Height*
Weight*
Contact Information
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Number Type*

Cell PhoneHome PhoneWork Phone
Additional Phone Number

Area CodePhone Number
Number Type*

Cell PhoneHome PhoneWork Phone
Email
example@example.com
Emergency Contact
In case of emergency notify *

First NameLast Name
Relation *
Phone Number*
Medical Doctor*
Clinic*
Medical Information
Allergies?*

YesNo
If yes, please list:*
List all medication you are currently taking, and the reason:
Drug
Reason
Drug
Reason
Drug
Reason
Drug
Reason
Drug
Reason
Drug
Reason
Drug
Reason
Drug
Reason
Drug
Reason
Drug
Reason
Pharmacy

Do you have any of the following? Check 'Yes' or 'No' and list the dates/details:*

	Yes	No	Date	Details
Seizures
High / Low Blood Pressure (list BP in details)
Stroke
Heart Condition (list type in details)
Heart Attack
Blood Disorders / Anemia / Clotting
Do you smoke, vape or use tobacco? (list amount per day in details)
Lung Disorder / Asthma / COPD
History of Sleep Apnea / Snoring
Cancer (list type in details)
Depression / Anxiety
Reflux
Ulcers
Kidney Disease
Diabetes (list type in details)
Thyroid Disease
History of Substance Abuse?
Hepatitis (A, B, C) / Jaundice / Liver Disease
HIV Infection / AIDS
Are you pregnant? (list due date)
Arthritis (list type in details)
Joint Replacement
Osteoporosis
Any operation under general anesthetic or sedation? (list date in details)
Do you have any eating disorders? (Anorexia, Bulimia, etc)

Important additional information:
WOMEN ONLY: Are you current breastfeeding?*

YesNo
Is there a family history of: life-threatening anesthetic complications, abnormal reactions to muscle relaxants, malignant hyperthermia or muscle problems (myopathy or muscular dystrophy)? If yes, please add details below:
Insurance Information

If the patient has a dental plan, please complete the following. If the patient isn't covered by dental insurance, please leave blank.

Primary Insurance

Secondary Insurance

How did you hear about our office?

Online SearchBuilding SignSocial MediaOnline ReviewsPrint AdvertisementCommunity EventFriend/Family Referral (specify name below)Referring Dentist or Other (specify below)
Referring info:
I hereby certify that this medical and dental history is accurate to the best of my knowledge.

I consent to the performing on dental and oral surgery procedures agreed to be necessary or advisable, including the use of anesthetic, further medications, anesthetics or IV sedation as indicated.

I also consent to the collection, use and disclosure of myself, my child's, or my ward's personal information as set out in the Personal Information Consent form which I have read.

I have full decision-making for any above-listed minor or ward of the court.

I understand that I am financially responsible to my dentist for the entire treatment of fees that may not be covered by my plan or exceed my plan maximum.
Date

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Contact Information