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FORMS & DOCUMENTS

Medical History Questionnaire

Your information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Phone (Home)(Required)

Phone (Business)

Address (Home)(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address (Business)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation

Who referred you to our office?

In case of emergency, we should notify:

Name(Required)

First

Relationship(Required)

Day-time Phone(Required)

Name of family doctor

Phone or address

Name of medical specialist

Area of specialty

Phone or address

Name of medical specialist

Area of specialty

Phone or address

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.

1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why?(Required)

Yes

No

Not sure, maybe

Please specify(Required)

2. When was your last medical checkup?(Required)

3. Has there been any change in your general health in the past year? If yes, please explain.(Required)

Yes

No

Not sure, maybe

Please specify(Required)

4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list.(Required)

Yes

No

Not sure, maybe

Please specify(Required)

5. Do you have any allergies? If you answered yes, please list using the categories below:(Required)

Yes

No

Not sure, maybe

a) medications b) latex/rubber products c) other (e.g. hayfever, foods)

Please specify(Required)

6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.(Required)

Yes

No

Not sure, maybe

Please specify(Required)

7. Do you have or have you ever had asthma?(Required)

Yes

No

Not sure, maybe

8. Do you have or have you ever had any heart or blood pressure problems?(Required)

Yes

No

Not sure, maybe

9. 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?(Required)

Yes

No

Not sure, maybe

10. Do you have a prosthetic or artificial joint?(Required)

Yes

No

Not sure, maybe

11. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?(Required)

Yes

No

Not sure, maybe

12. Have you ever had hepatitis, jaundice or liver disease?(Required)

Yes

No

Not sure, maybe

13. Do you have a bleeding problem or bleeding disorder?(Required)

Yes

No

Not sure, maybe

14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain(Required)

Yes

No

Not sure, maybe

Please specify(Required)

15. Do you have or have you ever had any of the following? Please check.(Required)

chest pain, angina

heart attack

stroke

shortness of breath

rheumatic fever

mitral valve prolapse

heart murmur

pacemaker

lung disease

tuberculosis

cancer

steroid therapy

diabetes

stomach ulcers

arthritis

seizures (epilepsy)

kidney disease

thyroid disease

drug/alcohol dependency

osteoporosis medications (e.g. Fosamax, Actonel)

16. Are there any conditions or diseases not listed above that you have or have had? If so, what?(Required)

Yes

No

Not sure, maybe

Please specify(Required)

17. Are there any diseases or medical problems that run in your family?(Required)

Yes

No

Not sure, maybe

(e.g. diabetes, cancer or heart disease)

Please specify(Required)

18. Do you smoke or chew tobacco products?(Required)

Yes

No

Not sure, maybe

19. Are you nervous during dental treatment?(Required)

Yes

No

Not sure, maybe

20. For women only: Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?(Required)

Yes

No

Not sure, maybe

Please specify your expected delivery date(Required)

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FORMS & DOCUMENTS

Medical History Questionnaire

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