Medical History

Personal Information
Dental Questionnaire
Medical Questionnaire

First Name

Last Name

Date of Birth ×

NAME YOU WANT TO BE CALLED:*

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PREFERRED PRONOUN:*

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Home Address

City Postal Code

Mobile Phone

Email Address

Employer

Occupation

Emergency Contact*

Emergency Contact Name

Emergency Contact Number

Contact Number

Name of Family Physician

Physician

Physician Number

Phone Number

Referred you to our office?*

Person responsible for this account*

Insurance Policy Holder*

Name and D.O.B

Group Plan/Policy #*

Insurance Company*

ID/Certificate #*

Smiley Rating Title*

Tell us something about your rating

When was your last dental visit?*

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How often do you brush your teeth?*

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When did you last have dental x-rays?*

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How often do you floss your teeth?*

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Have you been seeing a dentist regularly?

Yes

Not sure/Maybe

Do any of your teeth ache?

Yes

Not sure/Maybe

Have you ever been advised to take antibiotics before a dental appointment?

Yes

Not sure/Maybe

Have you ever been in a vehicle accident or experienced a blow to your jaw?

Yes

Not sure/Maybe

Have you ever had implant surgery?

Yes

Not sure/Maybe

Is there anything else not mentioned above regarding your past dental history?

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Are you being treated for any medical condition or have you been treated within the past year?

Yes

Not sure/Maybe

Please describe

When was your last medical checkup?

3. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list.

Yes

Not sure/Maybe

Do you have any allergies?

Yes

Not sure/Maybe

If yes, please list using the categories below

Medications

Latex/rubber products

Other (e.g. hayfever, foods)

Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.

Yes

Not sure/Maybe

Do you have or have you ever had asthma?

Yes

Not sure/Maybe

Do you have or have you ever had any heart or blood pressure problems?

Yes

Not sure/Maybe

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

Yes

Not sure/Maybe

Do you have a prosthetic or artificial joint?

Yes

Not sure/Maybe

Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?

Yes

Not sure/Maybe

Do you have a bleeding problem or bleeding disorder?

Yes

Not sure/Maybe

Have you ever been hospitalized for any illnesses or operations? If yes, please explain.

Yes

Not sure/Maybe

Do you have or have you ever had any of the following?

sleep apnea

heart attack

stroke

shortness of breath

chest pain, angina

mitral valve prolapse

heart murmur

pacemaker

lung disease

tuberculosis

cancer

steroid therapy

diabetes

stomach ulcers

artritis

seizures or epilepsy

hepatitis or liver disease

kidney disease

thyroid disease

drug/alcohol dependency

osteoporosis medication (e.g. Fosamax, Actonel)

skin condition

Are there any conditions or diseases not listed above that you have or have had? If so, what?

Yes

Not sure/Maybe

Do you smoke or chew tobacco products?

Yes

Not sure/Maybe

Are you nervous during dental treatment?

Yes

Not sure/Maybe

Do you smoke or chew tobacco products?

Yes

Not sure/Maybe

Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?

Yes

Not sure/Maybe

To the best of my knowledge, the above information is correct:

PATIENT/PARENT/GUARDIAN SIGNATURE

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Medical History

To the best of my knowledge, the above information is correct:

PATIENT/PARENT/GUARDIAN SIGNATURE

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