Patient Medical Questionnaire

Patient Medical Questionnaire
Your medical and dental health history are essential for the determination and course of your treatment in our office. It is important that you complete this questionnaire accurately as it will become part of your office record. Be assured that it will be held in strict confidence.
Once you've completed the form, press the Submit My Info button at the bottom! Fields marked with *()** are required fields.

*Title:
*First name:		*Last name:
*Birth date: (mm/dd/yyyy)	/ /
*Home Tel. Number:	( )	Business Tel. Number:	( )
*Street:		*City:
*Province:		*Postal Code:
Apt.		E-mail address:
*Do you have dental insurance?	YES NO	Policy/Group #
Insurance Company:		ID #
Name of Policy Holder:		Policy holder Birth Date:	/ /
Referring Dentist:
Other Dentists you see:
Family Physician		Tel. Number:	( )

Health History

Have you ever had an unfavourable reaction after a dental treatment? YES NO
Please discuss this with the doctor.

Have you ever had excessive bleeding requiring special treatment? YES NO
Please discuss this with the doctor.

Female patients, are you or could you be pregnant or nursing? YES NO

If pregnant, which month?

Do you wear contact lenses? YES NO

Check any of the following which you have or have had:
Heart trouble/Angina	High blood pressure	Stomach ulcer
Heart murmur	Anemia	Kidney disease
Antibiotics required	Rheumatic fever	Fainting spells
Asthma	Lupus	Sinus trouble
Diabetes	Nervous disorders	Neck injury
Arthritis	Cortisone treatment	Cancer treatment
Jaundice	Psychiatric treatment	Sickle cell disease
Stroke	Migraine/Headaches	Liver disease
Hemophilia	Emphysema	Thyroid disease
Epilepsy	Herpes	Alcoholism
Glaucoma	Hepatitis B or C	Mitral valve prolapse
Hepatitis A	Venereal disease	Artificial valve, joint, or prosthesis
Addictions	Congenital heart defect	Blood transfusions
TMJ problems	Cardiac pacemaker	Tuberculosis (TB)
HIV/AIDS

Do you have or have you had any other diseases or medical problems not listed on this form?

Please list allergies to medications/other substances

Please list medications currently being taken (include non-prescription drugs)

Dental History

Chief Complaint (reason for presentation)

Are you currently in pain? YES NO

Are any of your teeth sensitive to the following?
Hot Cold Biting pressure Sweets Other