Medical History Questionnaire
The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.
Medical Alert?
*
Yes
No
Date
*
-
Month
-
Day
Year
Date
REGISTRATION INFORMATION
This information will enable us to maintain communication with you.
Name
*
Prefix
First Name
initial
Last Name
Date of Birth
*
-
Month
-
Day
Year
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone:
Format: (000) 000-0000.
Occupation
Who referred you to our office?
IN CASE OF EMERGENCY
This information will enable us to make any essential contacts.
In case of an emergency contact:
*
First Name
Last Name
Emergency contact phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Family Physician:
Physician name
Last Name
Physician: Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Specialist:
First Name
Last Name
Specialist: Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain?
*
Yes
No
Not Sure/Maybe
If yes, please explain
When was your last medical checkup?
*
Has there been any change in your general health in the past year? If yes, please explain.
*
Yes
No
Not Sure/Maybe
If yes, please explain
Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list them.
*
Yes
No
Not Sure/Maybe
If yes, please list them
Do you have any allergies? If yes, please list them using the categories below:
*
Yes
No
Not Sure/Maybe
Medications:
Latex/rubber products:
Other (e.g. hay fever, seasonal/environmental, foods):
Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.
*
Yes
No
Not Sure/Maybe
If yes, please explain
Do you have or have you ever had asthma?
*
Yes
No
Not Sure/Maybe
Do you have or have you ever had any heart or blood pressure problems?
*
Yes
No
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
No
Not Sure/Maybe
Do you have a prosthetic or artificial joint?
*
Yes
No
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
No
Not Sure/Maybe
Have you ever had hepatitis, jaundice or liver disease?
*
Yes
No
Not Sure/Maybe
Do you have a bleeding problem or bleeding disorder?
*
Yes
No
Not Sure/Maybe
Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
*
Yes
No
Not Sure/Maybe
If yes, please explain
Do you have or have you ever had any of the following? Please check.
chest pain, angina
rheumatic fever
pacemaker
steroid therapy
seizures (epilepsy)
heart attack
mitral valve prolapse
lung disease
diabetes
kidney disease
stroke, TIA
tuberculosis
stomach ulcers
thyroid disease
shortness of breath
heart murmur
cancer
arthritis
drug/alcohol/cannabis use or dependency
osteoporosis medications
(e.g. Fosamax, Actonel)
Are there any conditions or diseases not listed above that you have or have had? If yes, please explain.
*
Yes
No
Not Sure/Maybe
If yes, please explain
Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?
*
Yes
No
Not Sure/Maybe
Do you smoke or chew tobacco products?
*
Yes
No
Not Sure/Maybe
Are you nervous during dental treatment?
*
Yes
No
Not Sure/Maybe
Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?
*
Yes
No
Not Sure/Maybe
Do you identify as a patient with a disability? If yes, please explain.
*
Yes
No
Not Sure/Maybe
If yes, please explain
To the best of my knowledge, the above information is correct:
Date
*
-
Month
-
Day
Year
Date
Patient/Parent/Guardian Signature:
*
Internal Use Only
Date
-
Month
-
Day
Year
Date
Dentist Signature:
Dentist's Notes
Submit
Should be Empty: