Name: __________________________________________________
Address: __________________________________________________
Phone: _______________  Birthdate: _____________   SIN:  _______________
Employer: ________________________________  Phone: __________________
Address: __________________________________________________
Spouse: _____________________  Employer: ________________  Phone: _________
Relative / Friend: ________________________________  Phone: __________________
Address: __________________________________________________
Physician: ________________________________
Referred by: ________________________________  Phone: __________________

Former Dentist: ________________________________

Medical History:
1. Weight: _____________, Male_____Female_____  Marital Status: ________________

2. Circle any of the following which you have had or now have:
    Aids, Allergies, Anemia, Arthritis, Artificial Heart Valves, Asthma, Cancer Treatment, Cardiac
    Pacemaker, Congental Heart Lesions, Cough, Diabetes, Epilepsy, Heart Murmur, Heart
    Trouble, Hemophilia, Hepatitis, Herpes, High Blood Pressure, HIV Pos., Jaundice, Kidney
    Disease, Lupus, Mononucleosis, M.S., Psychiatric Treatment, Sinus Trouble, Tuberculosis,
    Sexually Transmitted Diseases, Gastro Int., Lung Disease, Rheumatic Fever, If other
    Please State: ___________________________________________________    
3. Are you under the care of a physician now? ____________________________________
4. Do you Smoke? ___Drink?___Use Drugs?___or Other Medicine Regularly: _________
5. Have you experienced any unusual reaction to any of the following drugs? (Please Circle)
    Aspirin, Barbituates (sleeping pills), Codine, Iodine, Novocaine, Valium, Penicillin, Sulfa,
    or Other:_____________
6. Do you have any blood disorder such as anemia or hemophilia? ______________
Medical Update______________________
 
Date: ________________   Signature: ______________________________________