Patient Chart

Insurance Information

First Name *
Middle Name
Last Name *
Title (Mr./Mrs.)
Preferred Name
Birthdate
Gender
Marital Status
Address 1
Address 2
City
Prov
Postal Code
Email Address
Work #
Ext:
Home #
Cell #
Location
Emergency Contact Name
Relationship
Daytime Phone Number
Alberta Heath Care Card Number
Who referred you to our office?
Best Contact

Medical History

Physician's Name
Location
Phone #
Medical Specialist
Specialty
Phone #
When was your last complete physical exam?
Are you taking any pills. drug, medications or herbal supplements?
If yes, please describe
Do you have any prescription allergies?
If yes, check all that apply:
Other please list:
Do you have any allergies?
If yes, check all that apply:
Other please list:
Do you have a latex allergy?
Do you have a reaction to Epinephrine?
Do you have a problem with local anesthetic?
Do you Smoke, Vape or use Chewing Tobacco?
If yes, how often?
Do you drink Alcohol
If yes, How many drinks per week?
Do you have any history of health conditions?
If yes, check all that apply:
Other Please Specify
Do you have any infectious diseases?
If yes, check all that apply:
Other please list:
Do you have any respiratory diseases?
If yes, check all that apply:
Other please list:
Do you have any heart conditions?
If yes, check all that apply:
Other Please Specify:
Do you require pre-medication?
Do you have diabetes?
Do you take blood thinners?
Do you have any special needs?
If yes, check all that apply:
Other Please Specify:
Have you been hospitalized or had any surgery in the past 5 years?
If Yes, Please Explain:
Do you or have you felt hot or feverish anytime in the last 10 days?
Do you have any of these symptoms:
New or worsening cough?
New or worsening shortness of breath? Difficulty breathing?
Sore throat or painful swallowing? Runny nose?
Have you experienced a recent loss of smell or taste?
Have you returned from travel outside of Canada in the last 14 days?
Date:
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