Adult Health & Business Questionaire Form - Alberta - Canada
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1
2ADULT HEALTH & BUSINESS QUESTIONAIRE
(Confidential information necessary for your files and your health)
Today’s Date ________________
Patient’s Name (last)___________________________(first)______________________Birthdate_____________Age___________
Home # _______________________Cell # _________________E-mail_____________________________
Address ________________________________________________________City__________________Postal Code____________
Occupation ________________________ Work # ___________________
Nearest Relative/Spouse(last)____________________(first)______________Relationship:______________Home #_____________
(if other than spouse)
Address _______________________________________________________ City__________________ Postal Code_____________
(if different from Patient)
Occupation ____________________________ Work # __________________
Dentist ____________________________________________________ Physician ________________________________________
Please check box
Are you in good health?…………………………………………………………………………………..
1.
YES
NO
2.
Have you previously been or are currently under the care of a health care professional for any kind of
specific condition or syndrome?…………………………………………….……………………………
YES
NO
If Yes, explain: _______________________________________________________________
Have you ever been hospitalized or had a serious illness or accident?…………………………………...
3.
YES
NO
If Yes, explain:_______________________________________________________________
4.
Please list any medications you are currently taking.__________________________________________________________
5.
Please check any of these medications you may have taken in the past year:
Penicillin
Blood thinners
Digitalis
Other__________
Cortisone
Tranquilizers
Thyriod
Nitroglycerin
Dilantin
Aspirin
_____________________
6.
Please check any of the items below that you have ever a bad reaction to:
Local Anesthetics
Codeine
Insulin
Barbituates
LATEX
Ibuprofen Penicillin
Aspirin
Iodine
Metals: _______
Other____________
7.
Please list any illness you
currently have: __________________________________________________________________________________
ever had: _______________________________________________________________________________________
OVER
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Parent category: Life