Medical History Questionnaire

 
MEDICAL ALERT:
 
NAME: * MR.MISSMRS.MS.DR.     DATE OF BIRTH:

HOME ADDRESS: *
HOME PHONE: *   EMAIL: *
BUSINESS ADDRESS:
BUSINESS PHONE:   OCCUPATION:
WHO REFERRED YOU TO OUR OFFICE?

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

NAME:   RELATIONSHIP:

DAY-TIME 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?
YesNoNot Sure/Maybe   If yes, please explain:

2. When was your last medical checkup?

3. Has there been any change in your general health in the past year? YesNoNot Sure/Maybe
If yes, please explain:

4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? YesNoNot Sure/Maybe
If yes, please list them:

5. 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)

6. Have you ever had a peculiar or adverse reaction to any medicines or injections?YesNoNot Sure/Maybe
If yes, please explain:

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?YesNoNot Sure/Maybe
If yes, please explain.

15. Do you have or have you ever had any of the following? Please check.chest pain, anginarheumatic feverpacemakersteroid therapyseizures (epilepsy)heart attackmitral valve prolapselung diseasediabeteskidney diseasestroke, TIAtuberculosisstomach ulcersthyroid diseaseshortness of breathheart murmurcancerarthritisdrug/alcohol/cannabis use or dependencyosteoporosis medications (e.g. Fosamax, Actonel)

16. Are there any conditions or diseases not listed above that you have or have had? YesNoNot Sure/Maybe
If yes, please explain.

17. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?
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
If pregnant, what is the expected delivery date?

21. Do you identify as a patient with a disability? YesNoNot Sure/Maybe
If yes, please explain:

Confirmation: * I verify the information above is correct to the best of my knowledge.   Date: *

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