Medical History Update

Waterloo Emergency Dental Centre

258 King Street North, Unit #7,
Waterloo, Ontario, Canada N2J 2Y9
Phone: (519) 883-0505

Today's Date*

Patient Name*

First Middle Last

Gender

Family Status*

Date of Birth*

DD

MM

YYYY

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?*

Please Provide More Information:

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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