location_on 805 Development Dr ❘ Kingston, Ontario K7M 4W6
call(613) 389-8660
mail reception@davidgouettdentistry.com

805 Development Dr, Kingston, ON K7M 4W6

Tel: 613-389-8660 | Email: reception@davidgouettdentistry.com

# MEDICAL HISTORY Wisdom Teeth

Your co-operation in completing this questionnaire is essential to providing you with the highest standard of dental care. All information is strictly confidential.

Name:
Address:
City:
Postal Code:
DATE OF BIRTH:
Home #:
Cell #:
HEALTH CARD NUMBER:

## General Health Assessment

1. Are you having pain or discomfort at this time?
Yes No
2. Do you feel very nervous about having dental treatment?
Yes No
3. Have you ever had a bad experience in the dental office?
Yes No
4. Have you been a patient in the hospital during the past two years?
Yes No
5. Have you been under the care of a medical doctor in the past two years?
Yes No
6. Have you taken any medicine or drugs during the past two years?
Yes No
7. Are you allergic to (itching, rash, swelling of hands, feet or eYes) or made sick by penicillin, aspirin, codeine, or any other drug or medication?
Yes No
If Yes, please list
8. Have you ever had any excessive bleeding requiring special treatment?
Yes No

### PLEASE CIRCLE ANY OF THE FOLLOWING, WHICH YOU HAVE HAD OR HAVE AT PRESENT:

Heart Failure Emphysema Aids Heart Disease/Attack Cough Hep A B C Hay Fever Angina Pectoris High blood pressure Tuberculosis Asthma Liver Disease Heart Murmur Yellow Jaundice Rheumatic Fever Sinus Trouble Blood transfusion Congenital Heart lesions Allergies/hives Drug addiction artificial heart valve Thyroid disease Cold sores Pacemaker X-ray cobalt tmt Genital herpes Heart surgery Arthritis Chemotherapy Epilepsy/seizures Artificial Joint Anemia Fainting/Dizziness Rheumatism Nervousness Stroke Cortisone medicine Psychiatric Tmt Kidney Trouble Glaucoma Sickle Cell Disease Ulcers Pain in Jaw Joints

## Physical Wellness Indicators

9. When you walk up stairs or take a walk do you ever have to stop because of pain in our chest, shortness of breath or because you are very tired?
Yes No
10. Do your ankles swell during the day?
Yes No
11. Do you use more than 2 pillows to sleep?
Yes No
12. Have you lost or gained more than 10 pounds in the past year?
Yes No
13. Do you ever wake up from sleep short of breath?
Yes No
14. Are you on a special diet?
Yes No
15. Has you medical doctor ever said you have cancer or a tumor?
Yes No
16. Do you have any disease, condition or problem not listed?
Yes No
If Yes, please explain:

### WOMEN ONLY

Are you pregnant?
Yes No
Do you anticipate becoming pregnant?
Yes No

TO THE BEST OF MY KNOWLEDGE, ALL OF THE PRECEDING ANSWERS ARE TRUE AND CORRECT. IF I EVER HAVE ANY CHANGE IN MY HEALTH, OR IF MY MEDICATION CHANGES, I WILL INFORM THE DOCTOR AT THE NEXT APPOINTMENT WITHOUT FAIL.

Signature of Patient or Parent/Guardian
Date

### FINANCIAL AGREEMENT

Payment must be made the day of surgery. Our office will electronically file dental claims on your behalf if you have dental insurance.

Please provide us the appropriate insurance information:

Policy Holder's Name and Date of Birth:
Ins. Company:
Policy/Contract #:
Certificate:

A Charge of 200.00 for less than 48 hours' notice of cancellation appointment.