www.humbervalleydental.com - Medical History Questionnaire Form

Medical History Questionnaire
MEDICAL ALERT
Name

TitleFirst NameLast Name
Date of Birth

MonthDayYear
Address (Home)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address (Business)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Who referred you to our office?
In case of emergency, we should notify
Name
Relationship
Day - Time - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Family Doctor
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street, City, State, Zip
Name of Medical Specialist
Area of Specialty
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street, City, State, Zip
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
When was your last medical checkup?
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 them.
Do you have any allergies?
If yes, please list them using the categories below
a) Medications
b) Latex / Rubber Products
c) 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
Do you have or have you ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
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?
Do you have a prosthetic or artificial joint?
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
Have you ever had hepatitis, jaundice or liver disease?
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 or have you ever had any of the following? Please select
Are there any conditions or diseases not listed above that you have or have had?
If Yes, Please Explain
Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?
Do you smoke or chew tobacco products?
Are you nervous during dental treatment?
Are you breastfeeding or pregnant?
What is the expected delivery date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you identify as a patient with a disability?
If Yes, Please Explain
To the best of my knowledge, the above information is correct
Patient / Parent / Guardian Signature
Patient / Parent / Guardian Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Medical History Questionnaire

MEDICAL ALERT

In case of emergency, we should notify