Getting To Know You


The following form will help us get to know you better.

Your Full Name:

Your Preferred Nickname:

Date of Birth (DD/MM/YY):

Your Current Age:

 Years:

Months:

Your Gender:

 Male Female

Your Address:

 Street

City

Postal Code

Your Phone Number:

 Home:

Alternate:

Your email address:

Your Dentist's Name:

Your Physician's Name:

For Students

Father's Name:

Mother's Name:

School:

Grade:

Do you play a musical instrument?

Your Favorite Sports:

Your Hobbies:

# of Brothers and Sisters:

Confidential Medical History

Any change in your health in the last year?

 Yes No

Are you currently under the care of a physician?

 Yes No
If yes, describe:

Have you had any medical treatment of any kind in the last year?

 Yes No
If yes, describe:

Have you had any surgical operation of any kind?

 Yes No
If yes, describe:

Have you had blood transfusion?

 Yes No

Have you ever had an allergic reaction to any medication?

 Yes No
If yes, describe:

Have you ever been told not to take a specific medication?

 Yes No
If yes, describe:

Are you taking a prescription drug of any kind?

 Yes No
If yes, describe:

Are you taking a non-prescription drug of any kind?

 Yes No
If yes, describe:

Do you wear corrective lenses?

 Yes No

Are you pregnant?

 Yes No
If yes, anticipated date of delivery:

Do you use any tobacco products?

 Yes No
If yes, how often:

If you have any medical conditions not listed above, please describe:

Do you have, have you had or been treated for any of the following:

Thyroid Condition

 Yes No

Venereal Disease, Herpes II

 Yes No

Acquired Immune Deficiency Syndrome

 Yes No

Pacemaker

 Yes No
Type:

Hip or Joint Replacement

 Yes No

Allergy

 Yes No
Type:

Radiation or Chemical Therapy

 Yes No

Ear Infections

 Yes No

Chronic Sinus

 Yes No

Asthma

 Yes No

Hemophilia, Bleeding, or Blood Disorder

 Yes No

Arthritis

 Yes No

Rheumatic Fever

 Yes No

Heart Problems

 Yes No

High Blood Pressure

 Yes No

Low Blood Pressure

 Yes No

Anemia, Sickle Cell Disease

 Yes No

Epilepsy, Seizures

 Yes No

Fainting Spells

 Yes No

Diabetes

 Yes No
Type:

Hepatitis

 Yes No
Type:

Ulcers

 Yes No
Details:

Kidney Disorder

 Yes No

Enzyme Deficiency (ie G6PD)

 Yes No

Tuberculosis

 Yes No

Hydrocephalus

 Yes No

Anorexia, Bulemia

 Yes No

Hypothermia

 Yes No

AIDS Related Complex

 Yes No

Chemical Dependency

 Yes No

Thalassaemia, Major

 Yes No

Heart Murmur

 Yes No

Chronic Diarrhea

 Yes No