New Patient Medical History Form
MacEwan Dental Centre
Patient Full Name
*
Patient First Name
Patient Last Name
Parent/Guardian
First Name
Last Name
Date of birth
*
DD/MMM/YYYY or DD/MM/YYYY
What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you currently have dental insurance?
Family Physician name:
Family Physician Phone Number:
Please enter a valid phone number.
Do you have a regular dentist?
Please Select
Yes
No
If Yes, what is the name of the previous dental office/dentist. When was your last dental visit/cleaning?
In case of emergency, who should we contact?
*
*include full name and phone number
Have you been in the care of a medical Doctor in the past 2 years, or have you been hospitalized in the last 2 years?
Yes
No
If yes, please specify:
Indicate which of the following you have or ever had:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
AIDS
Anemia
Angina Pectoris
Arthritis/rheumatism
Artificial Heart Valve
Artificial Joints (hip,knee)
Blood disorders
Bronchitis
Cancer
Circulation Problems
Congenital heart lesions
Cortisone/Steriod
Diabetes
Emphysema
Seizures
Fainting or dizzy spells
Glandular disorders
Glaucoma
Head/Neck injuries
Heart disease/attack
Heart murmur
Heart pacemaker
Heart rhythm disorder
heart surgery
Hepatitis A B C
Herpes
high/low blood pressure
Hodgkins disease
Hyper/hypo Glycemia
Hypertension
Jaundice
Kidney/liver disease
Lung disease
Malignant Hyperthermia
Mitral valve prolapse
Organ transplant/medical implant
Psychiatric treatment
Radiation treatment/chemotherapy
Rheumatic/scarlet fever
Sickle cell disease
Sinus trouble
Stomach/intestinal problems
Stroke
Thyroid disease
Tuberculosis
Ulcers
Venereal Disease
NONE
Other
If other, please specify
Is there anything else about you health we should be made aware of?
Do you have any medication allergies?
*
Yes
No
Not Sure
Please list them.
Are you currently taking any prescription medication or NON-prescription medication?
*
Yes
No
Please list them.
Have you ever reacted adversely to any of the following? ANTIBIOTICS - Penicillin, Sulfonamide, other antibiotics, ASPRIN, BARBITURATES (sleeping pills), CODEINE, DARVON, LOCAL ANAESTHESIA, (freezing), NITRUS OXIDE, or been advised against taking any specific types of medication?
*
Please Select
Please Select
Yes
No
If yes, please list:
Do you have any of the following? Asthma, Hay fever, food allergies, METAL or LATEX allergies, skin rashes, Hives or any other allergic conditions? If YES: Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath or chest constriction?
*
Do you wish to speak to the doctor privately about any problem or medical condition?
Please Select
Yes
No
Have you been advised to take antibiotics BEFORE a dental appointment?
*
Please Select
Yes
No
Has anyone in your family have or had diabetes?
Please Select
Yes
No
Unknown
Do you bleed EXCESSIVELY from a cut or injury, or bruise easily?
Please Select
Yes
No
Do your ankles, feet or hands swell?
Please Select
Yes
No
Do you use any kind of tobacco or have you ever used them?
Please Select
Please Select
Yes
No
Do you experience shortness of breath or chest pain when climbing stairs
Please Select
Yes
No
have you tested HIV positive?
Please Select
Yes
no
Has your weight, appetite or energy levels changes dramatically recently, or do you follow a special diet?
Please Select
Yes
No
Do you have FREQUENT OR SEVERE headaches, earaches, ear/throat infections?
*
Please Select
Headaches
Earaches
Ear/throat infections
No
Have you ever had any injury or surgery to your face, jaws, or jaw joints?
*
Please Select
Yes
No
Do you wear glasses or contacts or have hearing difficulties?
Please Select
Glasses
Contacts
Hearing difficulties
None
Are you alcohol or drug dependent?
Please Select
Yes
No
WOMEN ONLY: Are you pregnant or suspect you might be? If Yes, what month? Are you taking any birth control or breast feeding?
CHILD: Has the child patient recently had any of the following? Checken pox, mumps, strep throat or tonsillitis
Please Select
No
chicken pox
mumps
strep throat/tonsillitis
I, the undersigned, certify that I have provided an accurate and complete medical history and have not knowingly omitted any information, I have had the opportunity to ask questions and receive answers to any questions about my medical history. I authorize the dentist to perform procedures and treatment as may be necessary and understand this treatment is for my immediate problem, and should not be regarded as a complete examination with resulting treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of these dental services is mine, and I assume responsibility for fees associated with these services.
*
Yes
No
Signature
*
Signed by:
*
Patient
Parent
Guardian
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