Patient Medical Information Form 1Your details & medical history2Conditions checklist3Consent & signature InstagramThis field is for validation purposes and should be left unchanged.Patient Name(Required) Mr.Mrs.MissMs.Dr.Prof. Prefix First Last Email(Required) Date of birth(Required) OccupationEmployerAddress(Required) Street Address Address Line 2 City Postal Code Referred ByTel — HomeTel — WorkTel — MobileEmergency Contact(Required)Emergency Contact Number(Required)Medical HistoryAnswer every question. If you answer Yes, a box will appear for extra detail.Are you being treated for any medical conditions at the present time or have been treated within the last year?(Required) Yes No Not Sure If so, why?When was your last medical check-up? Have there been any changes in your general health in the last year?(Required) Yes No Not Sure If yes, please explainAre you taking any medications, non-prescription drugs or herbal supplements of any kind?(Required) Yes No Not Sure If yes, please listDo you have any allergies?(Required) Yes No Not Sure If you answered yes, please list using the categories below.MedicationsLatex/Rubber ProductsOther (e.g. Hayfever, Foods)Have you ever had an uncommon or adverse reaction to any medicines or injections?(Required) Yes No Not Sure If yes, please explainDo you have or have you ever had asthma?(Required) Yes No Not Sure If yes, please explainDo you have or have you ever had any heart or blood pressure problems?(Required) Yes No Not Sure If yes, please explainDo you have or have ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?(Required) Yes No Not Sure Have you ever had hepatitis, jaundice or liver disease?(Required) Yes No Not Sure Which type of hepatitis?Do you have a prosthetic or an artificial joint?(Required) Yes No Not Sure If yes, please explainDo you have a bleeding problem or a bleeding disorder?(Required) Yes No Not Sure If yes, please explain Medical History (continued)Have you ever been hospitalized for any illness or operations?(Required) Yes No Not Sure If yes, please explainDo you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?(Required) Yes No Not Sure Conditions ChecklistDo you have or have you ever had any of the following? Please check all that apply. AIDS Alzheimers Angina Anemia Arthritis Blood Transfusion Cancer Chest Pain Cold Sores Diabetes Type 1 Diabetes Type 2 Digestive Disorders / Acid Reflux Drug / Alcohol Dependency Emphysema Epilepsy or Seizures Fibromyalgia Head/Neck Injury Heart Attack Heart Murmur High/Low Blood Pressure HIV Hodgkins Disease Hypo/Hyperglycemia Kidney Disease Lung Disease Lupus Migraine Mitral Valve Prolapse Osteoporosis Medications (e.g. Fosamax, Actonel) Pacemaker Parkinsons Disease Radiation/Chemotherapy Rheumatic Fever Sexually Transmitted Infection Shortness of Breath Sleep Apnea Steroid Therapy Stomach Ulcers Stroke Thrush Thyroid Disorder TMJ Disorder Tuberculosis Other HistoryAre there any conditions or disease not listed above that you have or have had?(Required) Yes No Not Sure If yes, please listAre there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)(Required) Yes No Not Sure If yes, please explainDo you smoke or chew tobacco products?(Required) Yes No Not Sure Are you nervous during dental treatment?(Required) Yes No Not Sure If yes, please explainAre you pregnant?(Required) Yes No Not Sure Before Your AppointmentHave you ever been advised to take antibiotics prior to a dental appointment?(Required) Yes No Not Sure If yes, please provide detailsAppointment PolicySimply Hygiene has a missed appointment fee of $50.00. This pertains to MISSED/NO SHOW or SHORT CANCELLATION appointments. We require a minimum of 48 business hours for changes to appointments.Missed appointment policy(Required) I have read and understand the missed appointment policy.(Required)DeclarationThe information I have given above is true to the best of my knowledge.Patient Signature(Required)Your NameYour NameYour NameYour NamePersonal Health Information Protection Act (PHIPA)PHIPA permits us to collect and use your personal health information. In certain circumstances, PHIPA also allows us to share it with others both inside and outside our organization. We do this for purposes such as:To provide you with health care;To get payment for your care which could include private insurers;To do health system planning and research;To report as required by law;Unless you tell us not to, we can share your personal health information with any health care provider who has, is or will be providing you with health care. Members of your health care team are only allowed access to the information they need to give you the care you need. If you tell us not to share your information with a health care provider, we will not share your information unless permitted or required by law to do so. Please tell a member of your health care team if you do not want your information shared with a health care provider.
