Medical History
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. Dr. Fairbairn will review the questions and explain any that you do not understand.
Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Occupation
Who referred you to our Office?
In Case of Emergency call:
First Name
Last Name
Phone number
Are you currently taking any medication?
*
Yes
No
When was your last medical checkup?
When was your last Dental checkup?
Check the conditions that you have had, or are currently being treated for:
Heart problems(chest pain, angina, heart attack)
Respiratory Disease(COPD, emphysema ,Shortness of breath,etc)
Asthma
Cardiac disease such as a previous heart attack
Heart valve replacement
High Blood pressure
Kidney disease
Blood disease(bleeding problem/disorder)
Lymphatic
Neurological(Stroke or TIA)
Psychiatric
Gastrointestinal(Crohns disease, Ulcerative colitis, etc.)
Genitourinary
Recent Weight gain
Recent Weight loss
Musculoskeletal(fibromyalgia, inflammatory arthritis, arthritis)
Diabetes
Prosthetic or artificial joint
Immune system disease(HIV, leukemia, chemotherapy, radiotherapy)
Liver disease such as hepatitis or jaundice.
Rheumatic fever
Mitral Valve prolapse
Tuberculosis
Cancer
Pacemaker
Stomach Ulcers
Steroid Therapy
Seizures(epilepsy)
If yes to any, please list medications here, including non-prescription or herbal drugs.
Has there been any changes in your general health in the past year? If yes, explain in the box provided.
Have you ever been hospitalized for an illness or an operation?
*
Do you have any medication or other allergies, such as latex or seasonal allergies?
Penicillin
Latex
Seasonal
Have you had any unusual reactions to medications or injections?
Are there any conditions or diseases not listed above that you have or have had?
What is your Gender?
Do you use or do you have history of using tobacco?
Please Select
Yes
No
Do you use or do you have history of using illegal drugs?
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Are you nervous during dental treatment?
*
Not nervous at all
Somewhat nervous
Nervous
Extremely Nervous
Do you identify as a patient with a disability? If Yes, please explain.
To the best of my knowledge, the above information is correct.
*
Submit
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