Medical History Update

Highland Kitchener Dentist

140 Highland Rd. West,
Kitchener, ON N2M 3B8
Phone: (519) 885-1598

Today's Date*

Patient Name*

First Middle Last

Gender

Family Status*

Date of Birth*

Age*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Email*

Work Phone

Extension Number

Are there any changes to your Health History?*

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Are you being treated for any medical condition at present or within 2 years?*

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Have you been hospitalized in last 2 years?*

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Allergies?*

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WOMEN ONLY : Are you pregnant or suspect you may be?*

List all medications currently being taken and reason for use : (including herbal, over the counter supplements)

Signature (Write your Name)*

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