Medical History Form MEDICAL HISTORY FORM Select one: MRMISSMRSMSDR Patient Name: * Date of Birth: (DD/MM/YYYY) Address (Home): Postal Code: Phone (Home): Phone (Bus): Email: Approx height: Approx weight: Who referred you to our office? IN CASE OF EMERGENCY, WE SHOULD NOTIFY Emergency Contact: Relationship with Contact: Contact Phone: Name of Family Dr: Phone of Family Dr: Address of Family Dr: Name of medical specialist (if any): Area of speciality: Phone: Address: Primary Insurance Information Subscriber Name: Subscriber DOB (DD/MM/YYYY): Policy or Group number: ID or certificate number: Insurance Company: Relationship to patient: Secondary Insurance Information Subscriber Name: Subscriber DOB (DD/MM/YYYY): Policy or Group number: ID or certificate number: Insurance Company: Relationship to patient: 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. Please ask us if you are uncertain about any of the questions. Please fill in the entire form. 1. Are you being treated for any medical condition at the present or have/you been treated within the past year? If so, why? YesNoNot sure 2. When was your last medical checkup? 3. Has there been any change in your general health in the past year? If yes, please explain. YesNoNot sure 4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list. YesNoNot sure 5. Do you have any allergies? If you answered yes, please list using the categories below: YesNoNot sure a) Medications: b) Latex/rubber products: c) Other: 6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain. YesNoNot sure 7. Do you have or have you ever had asthma? YesNoNot sure 8. Do you have or have you ever had any heart or blood pressure problems? YesNoNot sure 9. Do you have or have you ever had heart valve replacement, and infection of your heart (infective endocarditis), a heart condition from birth (congenital heart disease) or a heart transplant? YesNoNot sure 10. Do you have a prosthetic or artificial joint? YesNoNot sure 11. Have you ever been advised by your doctor to take antibiotics before dental treatment? YesNoNot sure 12. Do you have any conditions or therapies that could affect your immune system? e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy? YesNoNot sure 13. Have you ever had hepatitis, jaundice or liver disease? YesNoNot sure 14. Do you have a bleeding problem or bleeding disorder? YesNoNot sure 15. Have you ever been hospitalized for any illnesses or operations? If yes, please explain. YesNoNot sure 16. Do you have or have you ever had any of the following? Please check. chest pain, anginapacemakerarthritisrecreational drug useheart attacklung diseaseseizures (epilepsy)radiation therapystroketuberculosiskidney diseaseosteoporosis medicationshortness of breathcancerthyroid diseaserheumatic feversteroid therapydiet pill therapyIntravenousmitral valve prolapseddiabetesdrug/alcoholheart murmurstomach ulcerssleep apnea 17. Are there any conditions or diseases not listed above that you have or have had? If so, what? YesNoNot sure 18. Are there any diseases or medical problems that run in your family? (eg. diabetes, cancer or heart disease) YesNoNot sure 19. Do you smoke or chew tobacco products? YesNoNot sure 20. Are you nervous during dental treatment? YesNoNot sure 21. For women only: Are you breast-feeding or pregnant? If pregnant, what is the expected delivery date? YesNoNot sure I authorize release; to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same. I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history, and I have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentists to perform previously discussed diagnostic procedures and treatment as may be necessary for dental care. I also understand that consultation with my medical doctor may be required, and I consent my physician being contacted if necessary. I understand that responsibility for payment for dental services provided for myself or my dependants is mine, and I will assume responsibility for fees associated with these services. PATIENT/PARENT/GUARDIAN SIGNATURE: Date (DD/MM/YYYY): DENTIST SIGNATURE: Date (DD/MM/YYYY):
