Emergency Medical History

MEDICAL ALERT:*

Patient Name:* Date of Birth:*

Gender:*

Male Female Prefer not to disclose

Home Address:*

Home Phone:* Cell:

Email:

Occupation:* Allergies (Hay fever, seasonal, food):* Allergies to medications:*

Any allergies to following medications?

Penicillin or other antibiotics Sulfa drugs Aspirin/NSAIDS

Iodine/Silver Codeine

Family Physician Name and Phone:*

Emergency contact:

Name:* Phone:*

Relationship to patient:*

Please check mark any of the following that apply past or present:

Heart Attack Heart surgery Angina (Chest Pain) High blood pressure Low blood pressure Fainting/dizziness Infective Endocarditis Rheumatic fever Prolapsed mitral valve Artificial heart valves Heart murmur Congenital heart lesions Cardiac pacemaker Stroke Easy Bruising Excessive Bleeding Anemia Haemophilia

Von Willebrand Hives, skin rash Dermatitis Cancer treatment Radiation Therapy Chemotherapy Ulcers Gastritis Acid reflux Ulcerative colitis Gall bladder Jaundice Malaria Thyroid disease Tuberculosis Hiatus hernia Artificial joint/hip Arthritis

Disability Asthma Persistent cough Emphysema COPD Sleep apnea AIDS HIV infection Diabetes HbA1c Kidney trouble Liver ciarrhosis Depression Psychiatric treatment Anxiety Seizures/Epilepsy Hepatitis A/B/C/D/E Glaucoma Osteoporosis

Please list any medications you are presently taking:

Toothache/Tooth Injury:

Please rate the level of pain you are experiencing on a scale of 1-10

(1 being minimal and 10 extreme)*

Are you experiencing any of the following symptoms?

Throbbing Aching Shooting Numbness

Lingering Sharp Radiating

Are you experiencing any sensitivity?

Yes No

If yes, please advise Hot, Cold or Both

Hot Cold Both

How long ago did the injury occur:* Where did the injury occur:* Describe in your own words what happened:*

Is there any Lips/soft tissue bleeding, cuts, ulcerations, bruising

Yes No

(If bleeding occurred outside, it is advised to have a tetanus booster if you're not up-to-date on your vaccination)

If yes, please indicate which:

Is there any teeth movement, displacement, fracture, bleeding or discoloration?

Yes No

If yes, please indicate which:

If your tooth broke, do you have the missing piece?

Yes No

If your tooth got knocked out (avulsed), please see attached link to OPH

https://www.ottawapublichealth.ca/en/public-health-topics/resources/Documents/tooth_injury_en.pdf

Dental Insurance Information

Primary Insured's Name:* Date of Birth:* Insurance Company:*

Group #:* Policy #:*

Relationship to subscriber:*

Do you have dual coverage? If yes, list below

Secondary Insured's Name: Date of Birth:* Insurance Company:*

Group #:* Policy #:*

Relationship to subscriber:*

I give my consent for the dentist of this office to do an emergency dental examination on the patient listed above. X-rays that are necessary to properly complete the exam may be taken. I will be informed of any additional treatment that may be required and it will be fully explained to me prior to commencing. I agree to inform the doctors of any changes in my medical information and I authorize the release of any information relating to any dental claims. By signing this, I agree that the medical history is filled out to the best of my knowledge and I accept financial responsibility.

Please Sign Below:* Write your signature below.

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