Medical History Form Home / Medical History Form A parent/guardian will be responsible for decisions regarding my treatment YesNo First Name: Middle Name: Last Name: Address: City: Province: Postal Code: Birth Date: Home #: Health Card #: Cell #: Emergency Contact Name: Relationship: Phone #: Family Doctor: Phone #: Referred by: Phone #: Email Address: FINANCIAL INFORMATION Method of payment CashChequeCredit CardInsurance Insurance Holders Information: SelfSpouseParent/Guardian Name of Primary Ins. holder: Birth Date: Employer: Insurance Company: Policy/Contact #: Certificate ID#: Name of Secondary Ins. holder: Birth Date: Employer: Insurance Company: Policy/Contact #: Certificate ID#: Relationship: DENTAL HISTORY 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? Floss? Mouthwash? 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 MEDICAL HISTORY 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? Antibiotics/PenicillinSulfonamideAspirinCodeineDarvonBarbituratesOther 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 Measles Mumps Strep Throat NONE 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. Name: Date:
