Medical Dental History Questionnaire - Queen Street Dental Centre Page 2
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13. Do you have a bleeding problem or a bleeding disorder?
Yes
No
Not Sure/Maybe __________________________________________________________________
14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
Yes
No
Not Sure/Maybe __________________________________________________________________
15. Do you have or have you ever had any of the following? Please check.
chest pain, angina
rheumatic fever
lung disease
stomach ulcers
drug/alcohol
heart attack
mitral valve
tuberculosis
arthritis
dependency
stroke
prolapse
cancer
seizures (epilepsy)
osteoporosis
shortness of
heart murmur
steroid therapy
kidney disease
medications
breath
pacemaker
diabetes
thyroid disease
(e.g.Fosamax,
organ transplant
Actonel)
16. Are there any conditions or diseases not listed above that you have or have had? If so, what?
Yes
No
Not Sure/Maybe _________________________________________________________________
17. Are there any diseases or medical problems that run in your family?(e.g. diabetes, cancer or heart disease)
Yes
No
Not Sure/Maybe _________________________________________________________________
18. Do you smoke or chew tobacco products?
Yes
No
Not Sure/Maybe
How many per day?__________________Number of years?________
___________________________________________________________________________________________________________
FOR WOMEN ONLY
1. Are you pregnant?
Yes
No
Not Sure/Maybe
Expected delivery date? ________________________
Are you breastfeeding?
2.
Yes
No
3. Are you taking birth control medication?
Yes
No
___________________________________________________________________________________________________________
DENTAL HISTORY
1. Last dental visit? ______________________ 2. What was done at that visit? __________________________________
3. How frequently do you see your dentist? _______________________________________________________________
(16 or more x‐rays taken at the same time)
4. Have you ever had a full mouth series of X-rays
?
Yes
No
If yes, approximately when? ________________________________________________________________________
5. How would you describe your dental health at present?
Good
Fair
Poor
6. What are your present dental concerns, if any?
Bleeding gums
Crooked teeth
Cosmetic
Loose teeth
Bad Breath
Food Trapping
Toothache
Loose dentures
Missing teeth/spaces
Other _____________________________
7. Are you dissatisfied with the appearance of your teeth?
Yes
No
8. Have you had any teeth extracted due to accident, decay or gum disease?
Yes
No
If yes, please explain _____________________________________________________________________________
9. If yes, have you had any complications after the extraction?
Yes
No
10. Have you been taught PREVENTIVE ORAL HYGIENE?
Yes
No
11. Are you anxious during dental visits?
Yes
No
12. Do you think you might like to have your dental treatment done while you are sedated?
Yes
No
PATIENT CERTIFICATION AND CONSENT
I, the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent
information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics
or other prescribed drugs as indicated. I will assume full responsibility for the fees associated with these procedures. I agree to the privacy policies posted
in the reception area and consent to the electronic sharing of information with my insurance company for the purposes of processing insurance claims
and the determination of benefits. Unless other arrangements are made, payment is due at each office visit. Unpaid accounts may be subject to interest.
My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and the dentist. I authorize the
dentist to treat me and I assume fully responsibility for the fees. I am aware that 2 business days notice is required to change or cancel an appointment
without charge.
X _________________________________________________________
________________________________
SIGNATURE, PARENT OR GUARDIAN IF UNDER 18
DATE
_________________________________________________________
________________________________
DENTISTʼS SIGNATURE
DATE
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