Medical History Questionnaire Name: Mr./Miss/Ms./Dr Date of Birth (DD/MM/YYYY) Day: Month: Year: Address* (Home) Phone* Address (Business) Phone (Business) Occupation Who Referred You To Our Office? IN CASE OF EMERGENCY, WE SHOULD NOTIFIY: Name Relationship Emergency Contact Daytime Phone Name Of Family Doctor* Phone or Address* (1) Name Of Medical Specialist Area of Specialty Phone Or Address (2) 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 currently being treated for any medical condition or have you been treated within the past year?* If yes, please explain? YesNoNot Sure/Maybe 2. When was your last medical checkup?* 3. Has there been any change in your general health in the past year? If yes, please explain.*YesNoNot Sure/Maybe 4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list them.*YesNoNot Sure/Maybe 5. Do you have any allergies? If yes, please list them using the categories below:* YesNoNot Sure/Maybe a) Medications b) Latex/rubber products c) Other (e.g. hay fever, seasonal/environmental, foods) 6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.* YesNoNot Sure/Maybe 7. Do you have or have you ever had asthma?* YesNoNot Sure/Maybe 8. Do you have or have you ever had any heart or blood pressure problems?* YesNoNot 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?* YesNoNot Sure/Maybe 10. Do you have a prosthetic or artificial joint?* YesNoNot Sure/Maybe 11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* YesNoNot Sure/Maybe 12. Have you ever had hepatitis, jaundice or liver disease?* YesNoNot Sure/Maybe 13. Do you have a bleeding problem or bleeding disorder?* YesNoNot Sure/Maybe 14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.* YesNoNot Sure/Maybe 15. Do you have or have you ever had any of the following? Please check.* chest pain, angina heart attack stroke, TIA heart murmur rheumatic fever mitral valve prolapse tuberculosis cancer pacemaker lung disease stomach ulcers arthritis steroid therapy diabetes thyroid disease drug/alcohol/cannabis use or dependency seizures (eilepsy) kidney disease shortness of breath osteoporosis medications (e.g. Fosamax, Actonel) None of the above 16. Are there any conditions or diseases not listed above that you have or have had? If yes, please explain.* YesNoNot Sure/Maybe 17. Are there any conditions or diseases not listed above that you have or have had? If yes, please explain. YesNoNot Sure/Maybe 18. Do you smoke or chew tobacco products?* YesNoNot Sure/Maybe 19. Are you nervous during dental treatment?* YesNoNot Sure/Maybe 20. Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?* YesNoNot Sure/Maybe 21. Do you identify as a patient with a disability? If yes, please explain.* YesNoNot Sure/Maybe To the best of my knowledge, the above information is correct: Patient/Parent/Guardian Signature (Type Name) Date:
