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Patient Information
Your Name
*
First
Middle Name (if applicable)
Last
Email
*
Cell Phone
*
Home Phone
Mailing Address
*
Street Address
Address Line 2
City
Province...
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Age (Years)
*
Please enter a number from
1
to
99
.
Birth Date
*
DD slash MM slash YYYY
Height
*
Weight
*
Parent/Guardian
*
First
Last
Guardian Email
*
Sex/Gender
*
Male
Female
Prefer not to say
Other
Marital Status
Single
Married
Divorced
Prefer not to say
Other
Sask Health #
*
Additional Coverage
I have FNIHB coverage.
I have Supplimentary Health coverage.
FNIHB #
*
Supplementary Health #
*
(low income - NOT private insurance)
Referral Information
Physician/GP
*
Prefix...
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Prefix
First
Last
Dentist
*
Prefix...
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Prefix
First
Last
Referred By
*
Name of the person who referred you to us.
Prefix...
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Prefix
First
Last
Reason For Referral
*
Why did they refer you to our office?
Health History
Last Physical Exam
DD slash MM slash YYYY
Last Surgery
DD slash MM slash YYYY
Last Hospitalization
DD slash MM slash YYYY
Do you consider yourself to be in good physical health?
*
Yes
No
Are you taking any medications?
*
Prescription, Non-Prescription, Herbal Medicine, etc.
Yes
No
List All Medications
Click the (+) to add a new line.
Name of Medication
Prescription? (Y/N)
Add
Remove
Personal or Family History of General Anesthesia Problems?
*
Yes
No
If yes, explain:
Are you allergic to/have a reaction to any medications?
*
Lidocaine, penicillin, aspirin, etc
Yes
No
Do you have any other allergies?
*
Latex, etc
Yes
No
List Allergies
If you answered Yes to Allergies, please specify the allergy and type of reaction.
Allergy
Type of Reaction
Add
Remove
Women Only
Please check each of the following statements that apply to you.
I am pregnant.
I am trying to get pregnant.
I experience menstrual problems.
I am currently taking birth control pills.
Recreational Substances
Do you currently use or have you ever used:
Check all that apply.
Tobacco
Cannabis
Alcohol
Illegal Drugs
Specify Usage
If you checked any of the substances above, please enter the specific Type of substance, the number of Years you have used it for, and the Frequency of use (amount per week/month). Click the (+) to add a new line.
Type
Years
Frequency
Add
Remove
Medical Conditions
Do you have any of the following?
Damaged Heart Valve
Abnormal Bleeding
Mouth Sores
Persistent Cough
Rheumatic Heart Disease
Artificial Valve
Fainting Spells
Kidney Trouble
Swollen Glands
Blood Transfusions
Heart Murmur
Seizures
Tuberculosis
Low Blood Pressure
Radiation Therapy
Heart Attack
Liver Problems
Respiratory Problems
Transplant (Specify Type)
Thyroid Problems
Heart Trouble
Jaundice
Osteoporosis
HIV/AIDS
Anxiety/Depression
High Blood Pressure
Hepatitis (A,B,C)
Ulcer
Sexually Transmitted Disease
Epilepsy
Stroke
Sinus Trouble
Asthma
Cancer
COPD
Type I Diabetes
Type II Diabetes
Hay Fever
Other (Specify)
Explain Medical Conditions
If you checked any of the conditions above, please explain.
Disclaimer & Signature
How would you like to sign?
*
Select...
Digital Signature
Type Name
Signature
*
Patient Signature (or Parent/Guardian Signature if patient is under 18 years of age)
Type Name
*
Disclaimer
*
I have read and understand all of the above and have filled out the above information to the best of my knowledge.
Comments
This field is for validation purposes and should be left unchanged.
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