Dr. Dmytrowski, winner of the Faces Magazine Award for Ottawa's Favourite Dentist 2017

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MEDICAL HISTORY FORM

How would you rate your general overall health

Hospitalization for illness or injury

An allergic or bad reaction to any of the following

Swollen ankles, feet, hands

Heart problems, or cardiac stent within last 6 months

Angina or chest pain

History of infective endocarditis

Artificial heart valve, repaired heart defect (PFO)

Pacemaker or implantable defibrillator

Orthopedic implant (joint replacement)

Rheumatic or scarlet fever

A stroke (taking blood thinners)

Anemia or other blood disorder

Abnormal bruising or bleeding

Pneumonia, emphysema, shortness of breath

Asthma

Tuberculosis, measles, chicken pox

Sleep apnea, snoring or sinus problems

Kidney disease, dialysis

Liver disease

Jaundice

Thyroid, parathyroid disease, calcium deficiency

Hormone deficiency

High cholesterol or taking statin drugs

Stomach troubles(i.e.; ulcers)

Osteoporosis/osteopenia (taking bisphosphonates)

Autoimmune disease (i.e.lupus,rheumatoid arthritis)

Glaucoma or eye surgery

Contact lenses, hearing aid(s)

Head or neck injuries

Epilepsy, convulsions (seizures), fainting, dizzy spells

Neurologic disorders (ADD/ADAH, prion disease)

Viral infections and cold sores

STI/STD/HPV (i.e.; Syphilis, Gonorrhea)

HIV/AIDS

Tumor(s), abnormal growth(s)

Radiation therapy

Chemotherapy, immunosuppressive medication for what condition

Emotional difficulties, anxiety, depression

Psychiatric treatment

Alcohol/recreational drug use

Drug or alcohol dependency

Steroid therapy

Presently being treated for any other illness

Often feel exhausted or fatigued

Experiencing frequent headaches

Currently pregnant or breast feeding

Taking birth control medication