102A 420 2nd Street SW
Calgary, Alberta
T2P3K4
Phone: 403.770.6900 Fax: 403.770.6901
www.imaginedental.com
Client Name: Date:
Medical physician: Medical specialist:
Location: Location:
Telephone: Telephone:
Date of last visit: Date of last visit:
If you have received treatment from your medical doctor in the last two years, please describe the reason for the treatment.
NA
Do you believe you are in good health?
N Y
Describe any notable changes in your health in the past 2 years.
NA

Describe any reasons why you have been hospitalized in the past 2 years.
NA
Have antibiotics ever been suggested or prescribed prior to dental treatment?
N Y
List any medications you are currently taking either on your own (over-the-counter) or prescribed by your doctor.
NA

Have you ever been told that you or anyone with whom you have household contact with have or have ever had “MRSA”(Methicillin-resistant Staphylococcus) or “VRE” (Vancomycin-Resistant Enterococci) (either “colonized” or “infected”) or a “superbug”?
N Y
Have you been diagnosed with Creutzfeldt-Jakob (CJD) (sporadic, familial, or iatrogenic), Gerstmann-Straussler-Scheinker (GSS), fatal familial insomnia (FFI) or another prion disease?
N Y
Have you had many treatments with antibiotics within last 5 years? If so please describe.
N Y
Does your family have a history of malignant hyperthermia?
N Y
Are you currently taking diet pills?
N Y
Have you taken any corticosteroids in the last six months?
N Y
Describe any allergic or adverse reaction you have had to any drug, medication or anaesthetic (including painkillers and antibiotics).
NA
Are you allergic to latex, plastic bandages or metal?
N Y
List any additional allergies you have or substances to which you experience adverse reactions.
NA

Do you engage in an occupation or activities, which bring you into contact with needles, blood or blood products?
N Y
Recent exposure to infectious disease, e.g., measles, chicken pox or tuberculosis?
N Y
Recent travel to areas where endemic diseases are present?
N Y
Are your vaccinations up to date?
N Y
Describe any special dietary needs or preferences you have.
NA
Have you used Neuromodulators in the last 3 years (Botox, Xeomin, Dysport)
N Y
Are you interested in Neuromodulators (Botox, Xeomin, Dysport)?
N Y
Women Only
Are you currently taking birth control pills?
N y
Is there a chance you may be pregnant?
N Y
If YES, please specify your due date
Neural(Brain & Nerves)
Severe headaches ? N Y
Migraine headaches ? N Y
Fainting ? N Y
Dizzy spells ? N Y
Epilepsy or seizures ? N Y
Myoclonus or involuntary twitching ? N Y
Ataxia or lack of coordination ? N Y
Nervousness ? N Y
Dementia ? N Y
Sensory/communication disorder ? N Y
Psychiatric treatment ? N Y
Learning or behavioural disorder ? N Y
Eating disorder ? N Y
Dermal, Muscular & Skeletal
(Skin, muscles & bones)
Skin rashes ? N Y
Skin ulcers ? N Y
Skin cancer ? N Y
Arthritis ? N Y
Artificial joints ? N Y
Sore muscles ? N Y
Night sweats ? N Y
Osteoporosis ? N Y
Cardiovascular
(Heart & circulation)
Heart disease ? N Y
Heart attack ? N Y
If YES, date of last event: ? N Y
Heart failure ? N Y
Swollen ankles ? N Y
Angina ? N Y
High/low blood pressure ? N Y
Heart murmur ? N Y
Congenital heart defect ? N Y
Mitral valve prolapse ? N Y
Artificial valve ? N Y
Rheumatic fever ? N Y
Pacemaker ? N Y
Heart surgery or transplant ? N Y
Aneurysm ? N Y
Stroke ? N Y
Hematological (Blood)
Blood transfusion or products ? N Y
Easy bruising ? N Y
Bleeding tendency ? N Y
Anaemia ? N Y
Sickle cell disease ? N Y
Haemophilia ? N Y
Leukemia ? N Y
Respiratory
(Breathing)
Allergies ? N Y
Hay fever ? N Y
Sinus problems ? N Y
Asthma ? N Y
Chronic cough ? N Y
New Cough ? N Y
Shortness of breath ? N Y
Emphysema ? N Y
Cystic fibrosis ? N Y
Tuberculosis ? N Y
Endocrine
(Glands & hormones)
Diabetes ? N Y
Thyroid disease ? N Y
Hodgkin’s disease ? N Y
Glandular disorder ? N Y
Genitourinary (Bladder & kidney)
Jaundice ? N Y
Bladder problems ? N Y
Kidney problems ? N Y
Kidney transplant ? N Y
Sexually transmitted disease ? N Y
Urinary tract infection ? N Y
Painful urination ? N Y
Blood in urine ? N Y
HIV infection ? N Y
AIDS or AIDS-related
diseases
? N Y
Gastrointestinal(Stomach & intestines)
Ulcers ? N Y
Bowel disease ? N Y
Persistent diarrhea ? N Y
New onset diarrhea ? N Y
Hepatitis infection ? N Y
Type:
Liver disease ? N Y
Cirrhosis ? N Y
Other
Use tobacco ? N Y
Use alcohol ? N Y
Organ transplant ? N Y
Tumour or cancer ? N Y
Radiation therapy ? N Y
Chemotherapy ? N Y
Antimicrobial Therapy ? N Y
Additional Information: