429 Thorold Rd, Welland, ON L3C 3W4
(289) 273-7242
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Current Patient Medical History

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Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.

Are you being treated for any medical condition at the present or any time within the past year?
Has there been any change in your general health in the past year?
Are you taking any prescription, non-prescription medications, or herbal supplements?
Do you have any allergies?
Have you ever had a peculiar or adverse reaction to any medicines or injections?
Do you have or have you ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
Do you have any conditions which may affect your immune system (i.e leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
Have you ever had hepatitis, jaundice, or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illnesses or operations?
Do you have, or have ever had any of the following? (Please select any that apply to you)
Are there any conditions/diseases not listed that you have or have had?
Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?
For women only:
Are you pregnant?
Are you breastfeeding
Lifestyle & Habits

These questions help us understand factors that may affect your oral and overall health.

Do you currently smoke or use tobacco products?
Do you currently use vaping products?
Do you use cannabis or recreational substances?
How often do you consume alcoholic beverages?
Do you frequently consume sugary drinks, energy drinks, sports drinks, or other acidic beverages?
How often do you snack between meals?
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