Required fields are marked with asterisks (*)

Adult: Oral Health Clinic Patient Health History Form

Welcome to the Durham Region Health Department online medical and oral health history form for adult patients of the Oral Health Division.

Important

Please only complete this form if the following applies to you:

Before completing this form, please ensure you have the following information:

Encounter file number
A list of any medications taken (prescribed, over the counter, or supplements) as you will be required to provide the full name, dosage, and frequency for each (if applicable)
The name and phone number of your family doctor (if applicable)

Encounter file number

Date of birth

Phone number (as previously given to Oral Health staff)

If you have any questions about this form, please call 905-433-5511 ext. 4567.