Medical Dental History Questionnaire - Queen Street Dental Centre
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Medical & Dental History Questionnaire
BEFORE YOUR APPOINTMENT (Please Print)
IN CASE OF EMERGENCY, WE SHOULD NOTIFY
Title:
Miss
Name: ___________________________________
Miss
Title:
Name: ___________________________________
Relationship: _________________________________________
Date of Birth (day/month/year): ___________________________
Daytime Phone: ______________________________________
Home Address: _______________________________________
(1) Name of Family Doctor: ______________________________
Suite: __________ City: _________________________________
Phone or Address: _____________________________________
Province: _____________ Postal Code: ____________________
(2) Name of Specialist: _________________________________
Daytime Phone: _______________________________________
Area of Specialty: _____________________________________
Evening Phone: _______________________________________
Phone or Address: ____________________________________
Business Phone: ______________________________________
Email: _______________________________________________
Do you have Dental Insurance?
Yes
No
Place of Business: _____________________________________
How did you hear about our office? ________________________
Occupation: __________________________________________
MEDICAL HISTORY: 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 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?
Yes
No
Not Sure/Maybe __________________________________________________________________
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.
Yes
No
Not Sure/ Maybe __________________________________________________________________
4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list.
Yes
No
Not Sure/Maybe __________________________________________________________________
5. Do you have any allergies?
Yes
No
Not Sure/Maybe
If yes, please list using the categories below:
a) medications ______________________________________________________________________________
b) latex/rubber products _______________________________________________________________________
c) other (e.g. hayfever, foods) __________________________________________________________________
6. Have you ever had a peculiar or adverse reaction to any medicines or injections?
Yes
No
Not Sure/Maybe
If yes, please explain _____________________________________________________________________________
7. Do you have or have you ever had asthma?
Yes
No
Not Sure/Maybe
8. Do you have or have you ever had any heart or blood pressure problems?
Yes
No
Not Sure/Maybe
9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective
endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
Yes
No
Not Sure/Maybe
10. Do you have a prosthetic or artificial joint?
Yes
No
Not Sure/Maybe
11. Do you have any conditions or therapies that could affect your immune system,
(i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
Yes
No
Not Sure/Maybe
12. Have you ever had hepatitis, jaundice (other than at birth) or liver disease?
Yes
No
Not Sure/Maybe
OVER >>
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