Patient First Name:
Patient Last Name:
Health Care Card Number:
Dr. Andrew Doig
Dr. Ryan Gallagher
1. Are you in Good Health
2. Have you had an unusual reaction to drugs/medications? To what? i.e. Penicillin
3. Is your physician treating you now?
4. Are you taking any medication? (prescription or over the counter)
Pharmacy contact info
5. Do you smoke or use tobacco products?
6. Do you use recreational medical marijuana?
7. Do you have any allergies?
8. Do you experience shortness of breath?
9. Have you gained or lost excessive weight recently?
10. Do you have heart disease or murmur? Heart Attack?
If so, when?
11. Are your ankles often swollen?
12. Have you ever had radiation treatment?
13. For women only, are you any of the following?:
14. Have you had any of the following? (check all that apply):
High Blood Pressure
Because you have answered YES to any of the above questions we recommend that you contact 811 to be assessed.
Unfortunately, this also means that any appointments at our Dental Office should be rescheduled.
College Park Dental
3929 8th St E,
Phone: (306) 955-4611