MEDICAL HISTORY QUESTIONNAIRE

Name

In Case of Emergency Notify:

Date of Birth:

Relationship:

Address

Day-Time Phone

Phone

Family Doctor

Occupation

Address

Referred By

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 any that you do not understand. Please fill 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?

Yes

Why?

2. When was your last medical checkup?

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

YesYes

Not Sure

4. Are you taking any medications, non-prescriptive drugs, or herbal supplements of any kind?

Yes

Not Sure

5. Do you have any allergies? If yes, please list using the categories below.

Yes

Not Sure

a) Medications:

b) Latex / Rubber products:

c) Other e.g., hay fever, foods:

6. Have you ever had a peculiar or adverse reaction to any medications or injections? If yes, please explain:

YesYes

Not Sure

7. Do you or have you ever had asthma?

Yes

Not Sure

8. Do you or have you ever had a heart murmur, mitral valve prolapses or rheumatic fever?

Yes

Not Sure

9. Do you or have you ever had any heart or blood pressure problems?

Yes

Not Sure

10. Do you have a prosthetic or artificial joint?

Yes

Not Sure

11. Have you ever been advised by your doctor to take antibiotics before dental treatment?

Yes

Not Sure

12. Do you have any conditions or therapies that could affect your immune system? e.g., Leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?

Yes

Not Sure

13. Have you ever had hepatitis, jaundice, or liver disease?

Yes

Not Sure

14. Do you have a bleeding problem or disorder?

Yes

Not Sure

15. Have you ever been hospitalized for any illness or operations? If yes please explain.

YesYes

Not Sure

17. Are there any conditions or disease not listed above that you have or have had? If so, what?

Yes

Not Sure

What?

18. Are there diseases or medical problems that run in your family?(e.g. diabetes, cancer or heart disease)

Yes

Not Sure

19. Do you smoke or chew tobacco?

Yes

Not Sure

20. Are you nervous during dental treatment?

Yes

Not Sure

21. For women only: Are you pregnant or breast feeding? If pregnant, what is the expected delivery date?

Yes

Not Sure

what is the expected delivery date?

22. Do you use cannabis?

Yes

Not Sure

23. If yes, for what purpose do you use cannabis?

Medical

Recreational

Both

24. For what medical condition do you use cannabis?

25. How do you usually take cannabis?

Smoke

Vape

Ingest

26. Have you ever had any side effects with your cannabis use? If yes, what type of side effects?

YesYes

27. When did you last use cannabis?

28. In addition to cannabis, do you use any other recreational drugs?

Patient/Parent/Guardian Signature:

Clear

Date

DENTIST SIGNATURE:

Clear

Date

MEDICAL HISTORY QUESTIONNAIRE

MEDICAL HISTORY QUESTIONNAIRE

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 any that you do not understand. Please fill the entire form.

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