Medical History Questionnaire

Title

Name

Date of birth

Address

Phone Number

Alternate phone number

Do you consent to message reminders?

In case of emergency we should notify:

Phone Number

Name of family doctor:

Dr. phone Number

Area

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 anything that you do not understand. Please fill in the entire form.

Are you currently being treated for any medical condition or have you been treated within the past year? lf yes, please explain.

When was your last medicaI checkup?

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

Are you taking any medications, non-prescription drugs or herbal supplements of any kind? lf yes, please list them.

Do you have any allergies?

lf yes, please list them using the categories below:

Have you ever had a peculiar or adverse reaction to any medicines / injections or topical anesthetic gel? If yes, please explain.

If Yes, have you received treatment?

Please list in detail any other serious illness not shown above which you have or may have had:

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? lf yes, please provide details.

Do you have a prosthetic or artificial joint? lf yes, when was the surgery?

Do you require a premed?

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

Are there any conditions or diseases not listed above that you have or have had? lf yes, please explain.

Do you smoke or chew tobacco products?

Are you nervous during dental treatment?

Do you have a disability? lf yes, please explain.

Do you have or have you ever had sleep apnea? If yes, have you been treated? Please explain.

Have you ever had Oral Sedation, IV Sedation or General Anesthesia before?

Did you have any complications during or after that? If yes, please explain.

FOR WOMEN ONLY. Are you breastfeeding or pregnant? !f pregnant, what is the expected delivery date?

To the best of my knowledge, the above information is correct:

Patient / Parent / Guardian

Date

Hours

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