Medical / Dental Health History
All information will be treated with complete confidentiality.
TODAY'S DATE
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-
Day
-
Month
Year
Date
MEDICAL ALERT
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Mr/Mrs/Ms/Miss
Name
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FIRST NAME
LAST NAME
MIDDLE NAME INITIAL
GENDER:
*
MARITAL STATUS:
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DATE OF BIRTH (dd/mm/yyyy)
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/
Day
/
Month
Year
Date
HOME ADDRESS:
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Suite/Apt #
CITY/PROVINCE
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POSTAL CODE
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HOME TELEPHONE
MOBILE PHONE
*
OCCUPATION
*
BUSINESS TELEPHONE
EMAIL:
*
example@example.com
EMERGENCY CONTACT
*
RELATIONSHIP
*
TELEPHONE
*
Who may we thank for referring you
Physician and Dentist Information
PHYSICIAN NAME
*
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician Phone
*
DENTIST NAME
DENTIST ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DENTIST PHONE
Insurance Information
SUBSCRIBER NAME:
SUBSCRIBER DATE OF BIRTH:
/
Month
/
Day
Year
Date
RELATIONSHIP TO PATIENT:
INSURANCE COMPANY:
POLICY #:
CERTIFICATE ID:
Secondary Insurance
(COMPLETE IF APPLICABLE)
SUBSCRIBER NAME
SUBSCRIBER DATE OF BIRTH
RELATIONSHIP TO PATIENT
INSURANCE COMPANY
POLICY #
CERTIFICATE ID
Medical History
Please fill out the following information as best as possible. The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is treated with complete confidentiality. All questions will be reviewed with you and anything you do not understand will be fully explained.
Are you now being treated for any medical condition or have you been treated within the past year? If so, why?
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When was you last medical checkup?
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Has there been any change in your general health in the past year? If yes please explain.
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Do you have any allergies? If yes, please list them (ex: medications, latex / rubber, food etc)
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Have you ever had a peculiar or bad reaction to any medicines or injections? If yes, please explain.
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Are you taking any medications, non-perscription drugs, or herbal supplements? If yes, please explain the condition, drug, dosage, and frequency.
*
Do you use tobacco products? If yes, please describe product (cigarettes, cigars, cape, etc) , frequency of use, and years of using.
*
Do you have, or have you had any of the following diseases or problems:
chest pain, angina
rheumatic fever
pacemaker
steroid therapy
seizures (epilepsy)
osteoporosis medications (e.g. Fosamax, Actonel)
heart attack
mitral valve prolapse
lung disease
diabetes
kidney disease
stroke
tuberculosis
stomach ulcers
thyroid disease
shortness of breath
heart murmur
cancer
arthritis
drug/alcohol dependency
Do you have or have you had any other condition not mentioned above? If yes, please explain.
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Do you have or have you ever had a replacement or repair of a heart valve, an infection of the hear (i.e. infective endocarditis, a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
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Yes
No
Do you have a prosthetic or artificial join?
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Yes
No
Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, Chemotherapy?
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Yes
No
Have you ever had hepatitis, jaundice, or liver disease?
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Yes
No
Do you have a bleeding problem or bleeding disorder?
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Yes
No
Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
*
Are there any growths or sore spots in your mouth?
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Yes
No
Do you ever have a dry or burning mouth?
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Yes
No
Have you ever had an allergic reaction to "freezing" (local anaesthetic)?
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Yes
No
Do you have any present dental problems? If yes, please describe (i.e. sore teeth, sore gums, sensitivity to hot or cold, bleeding gums, etc.)
*
Have you ever been diagnosed with periodontal disease (gum disease, pyorrhoea)
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Yes
No
Have you had any difficult extractions in the past? If YES, when? What was done?
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When was your last dental visit? What was done?
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Female Clients Only
Are you pregnant or suspect you may be pregnant?
Yes
No
Are you taking birth control pills?
Yes
No
Do you anticipate becoming pregnant?
Yes
No
Are you taking hormone replacement?
Yes
No
Consent
I verify that I understand all the questions asked in the health questionnaire. I also verify the information given is correct and that I am 14 years of age or older. I have been informed that my physician / dentist may be contacted by letter / email / telephone in order to complete details of my medical / dental history. I hereby consent to my physician / dentist providing Markham Dental - General and Cosmetic Dentistry with any information in the regard that may help to ensure safe dental treatment.
Signature of patient, parent or guardian
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Date
*
/
Month
/
Day
Year
Date
Authorization: I authorize release, to my dental benefits plan administrator, information contained in claims submitted electronically.
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Signature of patient, parent, or guardian
I hereby assign my benefits, payable from claims submitted electronically to PROVIDERS AT MARKHAM DENTAL and authorize payment directly to him/her.
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Retention of Documents Relating to Your Care and Agreement. By signing this, you understand and agree that it is our policy to scan original documents in an electronic form. Further, you agree that any agreement bearing a scanned signature, which is printed from the electric form, has the same force and effect as the original.
*
Signature of patient, parent, or guardian
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