Patient details

So we can match this to the right chart.

First name

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Last name

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Date of birth

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Phone

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Family physician & clinic (optional)

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Medical conditions

Check everything that applies now or in the past. It all matters, even if it seems unrelated to teeth.

Heart & circulation

Heart disease / heart attack High blood pressure Heart murmur or valve issue Pacemaker Stroke Bleeding disorder / blood thinner use None of these

Breathing & lungs

Asthma COPD / emphysema Sleep apnea Chest problems / difficulty breathing None of these

Other conditions

Is your diabetes well controlled?

Yes Mostly No / not sure

Anything not listed above?

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Medications & allergies

Current medications and supplements

Write 'none' if none. Include blood thinners, bisphosphonates and inhalers — they change how we plan care.

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Allergies

Penicillin / antibiotics Local anesthetic (freezing) Latex Codeine / opioids ASA / NSAIDs Other No known allergies

Please describe your other allergies

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Do you smoke or vape?

No Occasionally Daily

Are you pregnant or nursing?

Not applicable No Yes — pregnant Yes — nursing

Confirm & sign

I confirm this medical history is complete and accurate to the best of my knowledge, and I will inform Dentistry @ Manotick of any changes to my health or medications.

I confirm the above is accurate *

Signature

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Medical History

Patient details

Medical conditions

Medications & allergies

Confirm & sign

Thank You — We've Got It!