Medical History Existing Patient – Belleville Family Dental Care

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Medical History Recall (for existing patients)

"*" indicates required fields

First Name*

Last Name*

Email Address*

Phone*

Please review your previous medical history and advise your dentist if there are any changes.

1.) Has there been any changes in your health, such as serious illnesses, hospitalizations or new allergies?*

Yes

No

Not Sure/Maybe

If yes, please specify.

2.) Are you taking any new medications or has there been any change in your medications?*

Yes

No

Not Sure/Maybe

If yes, please specify.

3.) Have you had a heart murmur diagnosed or had any change in an existing cardiac problem or murmur?

Yes

No

Not Sure/Maybe

4.) When was your last medical check-up?**

5.) Were any problems identified at your last check-up?*

Yes

No

Not Sure/Maybe

If yes, please explain.

6.) For women only: Are you breast-feeding or pregnant?*

Yes

No

Not Sure/Maybe

If pregnant, what is the expected delivery date?

I certify that to the best of my knowledge, the above information is correct:**

Yes I certify

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146 St Paul St, Belleville, ON, K8N 1B3, Canada
Call Us At: 613-966-1225 OR Contact Us Online

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