Patient Form

Patient Form

We Create Beautiful Smiles

Smilemakers is a modern dental clinic located in Fort Saskatchewan.
We offer comprehensive services from all fields of dentistry in addition to high-end dental equipment, all services are provided in a comfortable environment. New patients are welcomed with a complimentary oral health consultation.

Medical Dental Alert

This information will be used to help us to meet your needs more effectively and efficiently. Please be assured that the information is privately collected, securely protected and stored in your confidential patient records. It will not be shared with anyone outside of our office, for any reason. We manage patient records in a very safe and secure manner following leading industry-accepted methodologies.

Smilemakers is a modern dental clinic located in Fort Saskatchewan.
We offer comprehensive services from all fields of dentistry in addition to high-end dental equipment, all services are provided in a comfortable environment. New patients are welcomed with a complimentary oral health consultation.

Medical Dental Alert

This information will be used to help us to meet your needs more effectively and efficiently. Please be assured that the information is privately collected, securely protected and stored in your confidential patient records. It will not be shared with anyone outside of our office, for any reason. We manage patient records in a very safe and secure manner following leading industry-accepted methodologies.

Medical History

NOTE: If you are unsure of any of the following questions please mark them and ask the doctor for an explanation.

Is your doctor treating you now?

YesNo

Do you have heart disease or murmur?

YesNo

Have you ever had rheumatic fever?

YesNo

Do you have any allergies?

YesNo

Are you allergic to latex products? (e.g. swelling of lips after blowing up a balloon)

YesNo

Are you allergic to any medicine or drugs?

YesNo

Have you ever experienced any unusual reaction to any of the following drugs?

YesNo

aspirin, penicillin, iodine, sulfonarnide(sulfa), barbiturates(sleeping pills), local anaesthesia or other medicine.

Have you ever had any serious illness?

YesNo

Are your activities limited?

YesNo

Do you become breathless easily?

YesNo

Do you smoke or use smokeless tobacco?

YesNo

Do you suffer from high blood pressure?

YesNo

Do you have abnormal bleeding or bruising?

YesNo

Are your ankles often swollen?

YesNo

Have you gained or lost excessive weight recently?

YesNo

Are you presently taking any medicine?

YesNo

Do you faint easily?

YesNo

Do you have diabetes?

YesNo

Have you ever taken cortisone or steroids?

YesNo

Have you ever been hospitalized or had previous surgery?

YesNo

Do you have a reaction to jewellery?

YesNo

Are you presently pregnant?

YesNo

Have you ever had any radiation therapy about the head and jaws?

YesNo

To the best of your knowledge, are you In good health?

YesNo

Are you afflicted with, or have you ever been treated for any of the following?

Chest pain I Heart attackThyroid diseaseEpilepsyNervous tensionDizzinessAsthmaLung problemsArthritisCancerTuberculosisAIDS/HIVPsychiatric careStrokeAnaemiaBlood disordersKidney diseaseLiver diseaseVenereal diseaseHepatitis /JaundiceSinusitisUlcers / Stomach problemsMuscular dystrophy

PLEASE EXPLAIN

Contact Us & Get A Quick Appointment