EMERGENCY PATIENT MEDICAL HISTORY

Please describe your concern or emergency.

Take Photo (optional)

When did the pain or concern begin?

Pain Level?

	1	2	3	4	5

1 is None, 5 is Strong

Select on or more:

Rows	yes	no
Pain to Cold
Pain Hot
Spontaneous Pain
Pain Medication helps
Pain keeping me up at night
Pain when bitting down
Pain when releasing from a strong bite

When is the last time you saw a dentist?

Medical Alert :

Patient Name

TitleFirst NameMiddle nameLast Name

Preferred Name

Patient Gender

Spouses / Partner / other - Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Patient Birth Date

MonthDayYear

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Patient E-Mail

Please check your preferred method of contact for appointment confirmation:

Employer

Occupation

Are you a full-time student?

If yes, name of school

Marital Status:

How did you hear about our office?

Subscriber Name

Relationship to Patient

Subscriber DOB

Subscriber SSN/ID

Subscriber Employer

Insurance Company Name

Insurance Company Phone

Area CodePhone Number

Group / Plan / Policy Number

Subscriber Name

Relationship to Patient

Subscriber DOB

Subscriber SSN/ID

Subscriber Employer

Insurance Company Name

Insurance Company Phone

Area CodePhone Number

Group / Plan / Policy Number

Name

Relationship

Phone

Area CodePhone Number

Do you have a personal physician?

Physician's Name

Physician's Phone

Area CodePhone Number

Date of Last Medical Checkup?

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

If yes, please explain

Has there been any change in your general health in the past year? If yes, please explain.

Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list each one and condition used for.

If yes, please explain

Do you have any allergies (medications, latex, foods, environment)?

If yes, please list

Have you ever had a peculiar or adverse reaction to any medicines or injections?

If yes, please explain.

If yes, please list type and frequency of use

Do you have any artificial joints or implants?

If yes, please list along with date of surgery

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

If yes, please list

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?

Have you ever had hepatitis, jaundice or liver disease?

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

Do you have a bleeding problem or bleeding disorder?

Have you ever been hospitalized for any illnesses or operations?

If yes, please explain.

Do you have any of these conditions?

Rows	Yes	No
Anemia
Angina / Chest Pain
Asthma
Cancer
Chemotherapy
Diabetes
Difficulty Breathing
Drug / Alcohol dependency
Frequent Headaches
Fainting
Glaucoma
Heart Attack
Heart Murmur
High Blood Pressure
Joint Replacement
Kidney Disease
lung disease
Mitral Valve Prolapse
Pace Maker
Radiation Therapy
Rheumatic Fever
Seizures
Stroke
Steroid Therapy
Stomach Ulcers
Thyroid Problems
Tuberculosis
Osteoporosis medications

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

Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease).

Do you use tobacco, cannabis or vape?

If you do please explain

Are you nervous during dental treatment?

If Female, do you have any of these conditions?

Rows	Yes	No
Are you taking birth control pills?
Are you nursing?
Are you pregnant?

If you are pregnant, how many weeks?

Do you have any disease, condition or problem that you feel we should know about? If so, please describe

Please Read and Accept by Signing at the end of the email

I understand that if an appointment is booked, Orleans Gardens Dental Centre will evaluate, diagnose and prescribe if needed. Orleans Gardens Dental CANNOT guarantee treatment. They will however do their best to provide treatment, as it is always their goal to provide excellent care and service to their patients.

Patient Consent I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code, and I can ask to see the Code at any time. I agree that Orleans Gardens Dental Centre can collect, use and disclose personal information about me (patient requesting service in email) as set out above in the information about the office’s privacy policies.

DOCTORS SIGNATURE

Medical History Questionnaire

Insurance - Primary

Insurance - Secondary

IN CASE OF EMERGENCY:

Medical History