Patient Evaluation – Medical 2020

SMILE MATTERS DENTISTRY

40 GILLINGHAM DRIVE, UNIT 407

BRAMPTON, ONTARIO

L6X 4X7

Patient Evaluation – Medical 2020

At Smile Matters we care about our patients and their medical/dental health. It is our goal to provide the best possible treatment for you and your family. It is very important for us to know of any current changes (health/ dental) or developments including medications. Any information provided to our practice is kept private and is protected by doctor-patient confidentiality.

Name*:

Email*:

This questionnaire is simple update- please complete the following:

1. Have you travelled out of country the past month? If so where

2. Are you experiencing any fever, shortness of breath, cough?
YesNo

3. Has there been any changes in your health, serious illnesses, allergies or hospitalization, since your last visit with us?
YesNo

4. Are you taking any new medications or has there been any change in your medications?
YesNo

5. Please provide a list of all medications.

6. When was your last medical check up?

7. Were there any problems identified

8. Is there anything we should be aware of?

To the best of my knowledge, this medical history is accurate

Patient/Parent/Guardian Signature

Date

Dentist/Hygienist Signature

Date

Provider Notes: