Please enable JavaScript in your browser to complete this form.MEDICAL HISTORYAll information is private and confidentialName *Date HeightWeight1. Have you been hospitalized or had any operations? If yes, when was the surgery and what for? *YesNoWhen was the surgery and what for? *2. Have you or your relatives had problems with sedation or anesthesia including malignant hyperthermia? If yes, describe: *YesNoDescribe: *3. Are you currently taking medications or non-prescription drugs or supplements? If yes please list: *YesNoPlease list: *4. Do you have any drug allergies? If yes please list: *YesNoPlease list drug allergies: *5. Any other allergies(e.g. latex, eggs, meal, hay fever)? If yes list: *YesNoPlease list other allergies: *6. Please indicate if you have a history of the following:Heart problems(i.e. heart murmur, angina, irregular heartbeat) *YesNoLow/high blood pressure *YesNoStroke *YesNoDiabetes *YesNoHypoglycemia *YesNoAsthma, persistent cough, tuberculosis *YesNoJoint replacement surgery, If yes, when and what *YesNoWhen and what *Hepatitis, jaundice, or liver problems *YesNoKidney or thyroid *YesNoBleeding disorder or anemia *YesNoFainting, dizziness, nervous disorders *YesNoEpilepsy or seizures or convulsions *YesNoWear contact lenses *YesNoConditions that would affect your immune system(i. e . AIDS, HIV, Leukemia) *YesNoIf yes to any of the above, please explain:7. Are you a smoker? *YesNo8. Women: are you pregnant or nursing? *YesNoPatient Signature *Clear SignatureDate *OFFICE USE ONLYReviewed by:Other findings:ASAPULSEBPMessageSubmitCall or Email to book an appointment today! Our Services 416-299-1020 Appointment Booking Hours Mon: Closed Tues-Thurs: 10am – 7pm Fri-Sun: 9am – 5pm 1001 Sandhurst Circle, Unit 207 Scarborough, ON M1V1Z6 Book Appointment
