Medical History Questionnaire for New Patients

Name:* Date of Birth:*

Gender:*

Male Female Prefer not to disclose

Address:*

Home Phone:* Cell Phone:*

Occupation:* Email:*

Who referred you to our office?:*

In case of emergency, we should notify:

Name:*

Relationship:* Day-time Phone:*

Family Doctor: Family Doctor Phone:

(1) Name of Specialist:

(1) Area of Specialty: (1) Phone:

(2) Name of Specialist:

(2) Area of Specialty: (2) Phone:

The dental staff will review the medical form with you and answer any questions. Please fill the following questions:

Any treatment for a medical condition within the past year?

Yes No Not sure/Maybe

If yes, please explain: Last medical checkup?

Any changes to your general health in the past year?

Yes No Not sure/Maybe

If yes, please explain:

List of medications, non-prescription drugs, or herbal supplements (Please include doses taken):

Please also advise if you are taking any medications for blood thinners, osteoporosis, steroids, diabetes, high blood pressure

Any allergies to following medications?

Any allergies ie: hay fever, seasonal, foods?*

Any adverse reaction to medication or injections?

Yes No Not sure/Maybe

If yes, please explain:

Have you ever been hospitalized for any illness or conditions?

Yes No

If yes, please explain:

Please check mark any of the following that apply past or present:

Please elaborate further if you have the following conditions: a. Asthma attacks: (how many times is the puffer used) b. Prosthetic or artificial joint: (please include year of surgery): c. Bleeding problems or disorder: d. Replacement or repair to heart valve, infective endocarditis, heart condition from birth, or heart transplant: (please include year if applicable) e. Heart or blood pressure problems: f. Hepatitis, jaundice or liver disease: (please include year of diagnosis) g. Any conditions that cause immunosuppression: h. Form of disability:

i. Family history of diabetes, heart disease, cancer:

Yes No

If yes, whom?

Do use tobacco or other tobacco-like substances?

Yes No

If yes, frequency and how many years?

Previous Smoker?

Yes No

If yes, how many years smoke free?

Do you drink alcohol?

Yes No

If answered Yes, how many drinks per week?

Women only

Currently pregnant?

Yes No Not sure/Maybe

If yes, what is your expected delivery date?

Thinking of getting pregnant?

Yes No Not sure/Maybe

Are you currently breast feeding?

Yes No

Hormonal imbalances?

Yes No Not sure/Maybe

Dental History Questionnaire

Last time seen by dentist:* Last cleaning:*

Last dental x-rays:*

History of dental treatment if known:

Fillings: Implant/s:

Crown/s: Root canal/s:

Orthodontic treatment: Gum treatment:

Any complications?

Yes No

Oral hygiene habits:

a. Type of brush:

Electric Manual

b. Bristle type:

Extra soft Soft

Medium Hard

c. Toothpaste name: d. How often do you floss?

e. How often do you brush?

f. Do you use a water pick?

Yes No

g. Mouthwash:

Yes No

h. Do you use fluoride products?

Yes No

Check all that apply:

Are you happy with the colour of your teeth?

Yes No

Are you happy with present oral health/smile?

Yes No

I filled out this form to the best of my knowledge and confirm that the following information is correct.

Patient/Parent/Guardian Signature:*

Reset Signature