Medical History Form

A parent/guardian will be responsible for decisions regarding my treatment YesNo
First Name:
Middle Name:
Last Name:
Postal Code:
Birth Date:
Home #:
Health Card #:
Cell #:
Emergency Contact Name:
Phone #:
Family Doctor:
Phone #:
Referred by:
Phone #:
Email Address:


Method of payment CashChequeCredit CardInsurance
Insurance Holders Information: SelfSpouseParent/Guardian
Name of Primary Ins. holder:
Birth Date:
Insurance Company:
Policy/Contact #:
Certificate ID#:
Name of Secondary Ins. holder:
Birth Date:
Insurance Company:
Policy/Contact #:
Certificate ID#:


What is the reason for your visit today?
How frequent do you see a dentist? 3-6 monthsAnnuallyOther
Date of last dental visit?
Date of last x-rays?
How many times a day do you Brush?
Are your teeth sensitive to? ColdHeatSweetsOther
Do your gums bleed when? BrushingFlossingNeverOther
Are you satisfied with your teeth?YesNo
Do your gums feel swollen or tender?YesNo
Do you have bad breath or a bad taste in your mouth? YesNo
Does your jaw crack/pop/grate when opening wide? YesNo
Does food get trapped between your teeth? YesNo
Do you clench or grind your teeth? YesNo
Have you had local anesthetic? YesNo
Have you had complications from it? YesNo
Have you had complications from dental work? YesNo
Have you ever had any of the following?BridgeCrown/CapDenturesBracesRoot Canal


Are you under the care of a physician?YesNo
Have you ever been hospitalized?YesNo
Are you on any medications? YesNo
Medication List:
Are you currently taking Anticoagulants (e.g. Coumadin)?YesNo
Have you had an adverse reaction to any of the following?
Have you been told to avoid any medications? YesNo
Ever taken prolonged medical/non-medical drugs?YesNo
Do you have any allergies? (i.e. latex, mint, anesthetics etc.) YesNo
Do you bruise easily or have prolonged bleeding? YesNo
Have you ever fainted, had shortness of breath or chest pain? YesNo
Do you smoke tobacco products?YesNo
Do you use a vape?YesNo
Do you use cannabis products?YesNo
Are you pregnant?YesNo
Use birth control?YesNo
Reached menopause? YesNo
Do you currently have, or have ever had any of the following?
Please check all that apply: None
AIDSAnemiaAngina PectorisArtificial Heart ValveArthritis/RheumatismArtificial JointsAsthmaBlood DisordersAnorexia NervosaBronchitisBulimiaCancerCirculation ProblemsCongenital Heart LesionCortisone/Steriod treatmentDiabetesDrug/Alcohol DependencyEmphysema
EpilepsyGlandular DisordersGlaucomaHead/Neck InjuriesHeart Disease/AttackHeart MurmurHeart Surgery/PacemakerHeart Rhythm DisorderHepatitis A/B/CHerpesHigh/Low Blood PressureHIV PositiveHodgkin's DiseaseHyper/Hypo GlycemiaHypertensionJaundiceKidney DiseaseLiver Disease
LeukemiaLung DiseaseMalignant HypothermiaMental/Nervous DisordersMitro Valve ProlapseOrgan TransplantPsychiatric DisordersRadiation/ChemotherapyRheumatic/Scarlet FeverSickle Cell DiseaseSinus TroublesStomach Intestinal IssuesStrokeThyroid DiseaseTuberculosisUlcersVenereal DiseaseOther
CHILDREN: Have they had any of the following? Include Approximate dates.
Chicken Pox
Strep Throat
General Release: I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that the information I have provided is correct and haven’t knowingly omitted data. I consent to the release of the medial information from my medical doctor or health care provider as is required by this office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment.