Medical Update Form

Step 1 of 3 - Personal Information

33%

Name*
First Name Last Name
Date of Birth*
What's your main concern right now?*
Do your Gums feel tender/swollen?*
- Yes
- No
Do your Gums bleed?*
- Yes
- No
Do you have bad breath or a bad taste in your mouth?*
- Yes
- No
Have you had excessive bleeding during past dental visits?*
- Yes
- No
Do you grind/clench your tooth or notice any popping/clicking noises?*
- Yes
- No
Do you wear a night guard?*
- Yes
- No
Do you suffer from frequent migraines?*
- Yes
- No
Is snoring a problem for you?*
- Yes
- No
Are you happy with the way your smile looks?*
- Yes
- No

Do you have any serious Medical Conditions we should know about?*
- Yes
- No
Please explain.
Known Medical Conditions
- Alcohol/ Drug Abuse
- Angina
- Arthritis
- Asthma
- Blood Disorder
- Cancer
- Chemotherapy
- Congenital Heart Defect
- Diabetes
- Dizziness/Fainting
- Emphysema
- Epilepsy/Seizures
- Frequent Headaches
- Gag Reflex
- Hay Fever
- Head Injuries
- Hearing Disabled
- Heart Attack
- Heart Murmur
- Hemophilia
- No Known Medical Issues
Please select each Medical Condition that is applicable for you!
Known Medical Conditions cont'd
- Hepatitis A/B/C
- High Blood Pressure
- HIV/AIDS
- Joint Replacement (hip, knee, etc)
- Kidney Disease
- Liver Disease
- Low Blood Pressure
- Lung Disease/ Tuberculosis
- Mental Disorder
- Mitral Valve Prolapse
- Multiple Sclerosis
- Pacemaker
- Radiation Therapy
- Respiratory Problems
- Sinus Problem
- STD
- Stomach/Intestinal Problems
- Stroke
- Thyroid Disorder
- Ulcer
- Other
If Other selected, please specify:*
Do you have any allergies to medication or substances?*
- Yes
- No
What Allergies do you have?
Are you taking any prescription medication or herbal remedies? (including cannabis)*
- Yes
- No
Please list off your medications*
Do you need to be medicated with antibiotics prior to dental treatment*
- Yes
- No
Do you smoke or use chewing tobacco?*
- Yes
- No
Have you ever been treated for any other illness not listed above?*
- Yes
- No
If Yes selected, please specify:*
Are you pregnant and/or nursing?*
- Pregnant
- Nursing
- No
How far along is your pregnancy?*

Have you recently been under the care of a physician?*
- Yes
- No
Name of Physician*
Physician's Phone Number*
When was your last visit with the physician?*
Current Health Condition*
- Excellent
- Good
- Fair
- Poor
I am aware of Parkway Smiles Dental's cancellation policy which states that short notice cancellations within 48 business hours or failure to come for appointments may result in a $150 fee.*
Signature*

Dentistry Made Simple.

Thanks For Filling In Our Form.

2045 Symons Valley Pkwy NW #3010,
Calgary, AB T3P 0Y2

403-452-2833
reception@parkwaysmiles.ca

How Our Dentists Can Help

Invisalign
Dental Exams
Implants & Veneers
Children's Dentistry
Book Now

Communities Our Clinic Serves

Evanston
Livingston
Sage Hill
Carrington

About
- Our Office
- Our Team
  - Dr. Jeff Bullock
  - Dr. Do Hyun Sung
Services
Orthodontics
Contact Us

Phone-square-alt Mail-bulk Facebook

About
- Our Office
- Our Team
  - Dr. Jeff Bullock
  - Dr. Do Hyun Sung
Services
Orthodontics
Contact Us