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David Gouett Dentistry

Address

805 Development Dr, Kingston, ON K7M 4W6

Tel: 613-389-8660 | Fax: 613-389-9003

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.

General Health Assessment

1. Are you having pain or discomfort at this time?
2. Do you feel very nervous about having dental treatment?
3. Have you ever had a bad experience in the dental office?
4. Have you been a patient in the hospital during the past two years?
5. Have you been under the care of a medical doctor in the past two years?
6. Have you taken any medicine or drugs during the past two years?
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?
8. Have you ever had any excessive bleeding requiring special treatment?

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

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?
10. Do your ankles swell during the day?
11. Do you use more than 2 pillows to sleep?
12. Have you lost or gained more than 10 pounds in the past year?
13. Do you ever wake up from sleep short of breath?
14. Are you on a special diet?
15. Has you medical doctor ever said you have cancer or a tumor?
16. Do you have any disease, condition or problem not listed?

WOMEN ONLY

Are you pregnant?
Do you anticipate becoming pregnant?

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.

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:

A Charge of 75.00 for less than 48 hours' notice of cancellation appointment.