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.
Address (Business)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
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.
Name of Family Doctor
Phone Number
Please enter a valid phone number.
Address
Street, City, State, Zip
Name of Medical Specialist
Area of Specialty
Phone Number
Please enter a valid phone number.
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?*

YesNoNot 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?*

YesNoNot Sure / Maybe
If Yes, Please Explain*
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

YesNoNot Sure / Maybe
If yes, please list them.*
Do you have any allergies?*

YesNoNot Sure / Maybe
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?*

YesNoNot Sure / Maybe
If Yes, Please Explain*
Do you have or have you ever had asthma?*

YesNoNot Sure / Maybe
Do you have or have you ever had any heart or blood pressure problems?*

YesNoNot 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?*

YesNoNot Sure / Maybe
Do you have a prosthetic or artificial joint?*

YesNoNot Sure / Maybe
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

YesNoNot Sure / Maybe
Have you ever had hepatitis, jaundice or liver disease?*

YesNoNot Sure / Maybe
Do you have a bleeding problem or bleeding disorder?*

YesNoNot Sure / Maybe
Have you ever been hospitalized for any illnesses or operations?*

YesNoNot Sure / Maybe
If Yes, Please Explain*
Do you have or have you ever had any of the following? Please select

Chest Pain, AnginaHeart AttackStroke, TIAHeart MurmurRheumatic FeverMitral Valve ProlapseTuberculosisCancerPacemakerLung DiseaseStomach UlcersArthritisSteroid TherapyDiabetesThyroid DiseaseDrug / Alcohol / Cannabis use or DependencySeizures (Epilepsy)Kidney DiseaseShortness of BreathOsteoporosis Medications (e.g. Fosamax, Actonel)
Are there any conditions or diseases not listed above that you have or have had?*

YesNoNot 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)?*

YesNoNot Sure / Maybe
Do you smoke or chew tobacco products?*

YesNoNot Sure / Maybe
Are you nervous during dental treatment?*

YesNoNot Sure / Maybe
Are you breastfeeding or pregnant?*

YesNoNot Sure / Maybe
What is the expected delivery date?*

MonthDayYear
Date
Do you identify as a patient with a disability?*

YesNoNot Sure / Maybe
If Yes, Please Explain*
To the best of my knowledge, the above information is correct
Patient / Parent / Guardian Signature*

Clear
Patient / Parent / Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Medical History Questionnaire

MEDICAL ALERT

In case of emergency, we should notify