Dentist in Richmond | Dr. Robert Oliveros

604-275-3361

richmond dentist
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Medical History Form

Home » Medical History Form

What is your estimate of your general health?
1.Hospitalization for illness or injury
2.Do you have any allergies

If yes please check any that apply

3. Heart problems, or cardiac stent within the last six months
4. History of infective endocarditis
5. Artificial heart valve, repaired heart defect (PFO)
6. Pacemaker or implantable defibrillator
7. Artificial prosthesis (heart valve or joints)
8. Rheumatic or scarlet fever
9. High or low blood pressure
10. A stroke (taking blood thinners)
11. Anemia or other blood disorder
12. Prolonged bleeding due to a slight cut (INR > 3.5)
13. Emphysema, sarcoidosis
14. Tuberculosis
15. Asthma
16. Breathing or sleep problems (i.e. snoring, sinus)
17. Kidney disease
18. Liver disease
19. Jaundice
20. Thyroid, parathyroid disease, or calcium deficiency
21. Hormone deficiency
22. High cholesterol or taking statin drugs
23. Diabetes (HbA1c)
24. Stomach or duodenal ulcer
25. Digestive disorders (i.e. gastric reflux)
26. Osteoporosis/osteopenia (i.e. taking bisphosphonates)
27. Arthritis
28. Glaucoma
29. Contact lenses
30. Head or neck injuries
31. Epilepsy, convulsions (seizures)
32. Neurologic problems (attention deficit disorder)
33. Viral infections and cold sores
34. Any lumps or swelling in the mouth
35. Hives, skin rash, hay fever
36. STI / STD
37. hepatitis
38. HIV / AIDS
39. Tumor, abnormal growth
40. Radiation therapy
41. Chemotherapy
42. Emotional problems
43. Psychiatric treatment
44. Antidepressant medication
45. Alcohol / street drug use
46. Presently being treated for any other illness
47. Aware of a change in your health (i.e. fever, new cough)
48. Taking medication for weight management (i.e. fen-phen)
49. Taking dietary supplements
50. Often exhausted or fatigued
51. Experiencing frequent headaches
52. A smoker, smoked previously or use smokeless tobacco
53. Considered a touchy person
54. Often unhappy or depressed
55. FEMALE - taking birth control pills
56. FEMALE - pregnant
57. MALE - prostate disorders

Medical History Form - image dental-appointment on https://www.drrobertoliveros.com
Medical History Form - image dental-appointments on https://www.drrobertoliveros.com

Hours of Operation

Monday 9:00AM - 6:00PM
Tuesday 9:00AM - 5:00PM
Wednesday 9:00AM - 5:00PM
Thursday 8:00AM - 6:00PM
Friday Closed
Saturday 8:00AM - 5:00PM *
Sunday Closed

* We are open one Saturday a month.

Late appointments available upon request.

  • Home
  • Meet Dr. Oliveros
  • Before & After
  • Financial Info
  • FAQ’s
  • Promotions
  • Contact Us

  • Preventive Dentistry
  • General Dentistry
  • Cosmetic Dentistry
  • Periodontal Disease
  • Implants
  • Orthodontics

Dr. Robert Oliveros Inc.

Suite 220 - 6180 Blundell Road
Richmond, BC V7C 4W7

Phone: 604-275-3361
Fax: 604-275-3085
email: info@drrobertoliveros.com

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  • Home
  • Meet the Team
    • Meet Dr. Oliveros
    • Meet the staff
    • Back
  • Services
    • Preventive Dentistry
      • Digital X-rays
      • Dental Exams and Cleanings
      • Dental x-rays
      • Fluoride
      • Sealants
      • Back
    • General Dentistry
      • Composite Fillings
      • Crowns (Caps)
      • Bridges
      • Inlays/Onlays
      • Root Canal Treatment
      • Complete & Partial Dentures
      • Extractions
      • Mouthguards
      • Back
    • Cosmetic Dentistry
      • Porcelain Crowns
      • Porcelain Veneers
      • Porcelain Bridges
      • Porcelain Inlays/Onlays
      • Teeth Whitening
      • Back
    • Periodontal Disease
      • Diagnosis
      • Treatment
      • Periowave™
      • Maintenance
      • Back
    • Orthodontics
      • Invisalign
      • Back
    • Back
  • Gallery
    • Before & After
    • Back
  • Financial Info
  • FAQ’s
  • Promotions
  • Contact Us
    • New Patient Forms
      • Medical History Form
      • Dental History Form
      • Back
    • Back
  • Blog
Welcome Back

We are excited to tell you that we are open once again and welcome you back! We have always prided ourselves in providing a safe and clean environment, but in light of the COVID-19 Pandemic we have instituted additional guidelines and protocols to ensure your safety.

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