Name:____________________________________________________________________Date of Birth: ______________________________________________________________Address:_______________________________________________________Apt:________City:________________________________________________ Postal Code:___________Phone: Home____________________ Cell__________________ Work________________Alternate Contact Information:__________________________________________________

Please check all that apply: Alzheimer’s / Dementia Arthritis/Gout Artificial Joint(s) Asthma Anxiety &/or Depression COPD Cancer Chemotherapy Cold sores/ oral lesions Diabetes I Dialysis/Renal Therapy Epilepsy/Seizures Diabetes II Heart Attack High Cholesterol Drug &/or Alcohol Dependency Pacemaker High Blood Pressure Irregular Heartbeat Organ Transplants Low Blood Pressure Hepatitis A Radiation Treatment Stomach/Intestinal Issues Hepatitis B Recent Weight Loss Stroke Hepatitis C Sinus Complications Vertigo Osteoporosis HIV/AIDS Tumors or Growths Tuberculosis (TB) Thyroid Disease Ulcers

Any other health issues not listed above:_________________________________________Family Physician:___________________________________________________________Last Medical Visit: __________________________________________________________Are you taking any medications? We will photocopy a list if you have one with you. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you have any allergies? If yes, please specify: ____________________________________________________________________________

How did you hear about us? I was referred by my dentist I was referred by a friend _________________ I saw the ad in the Sault Star I found your information online I visited the website Local phonebook Word of mouth Other: ________________________________