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Medical History Form

HomeMedical History Form

Updated Medical History

if you are a current patient, please ensure you update us on any changes to your health. 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.

Patient Type *AdultChildAdult Under Guardianship

First Name of Guardian *

Last Name of Guardian *

Self Identification *ManWomanOther

First Name of Patient *

Last Name of Patient *

Date of Birth *

Has there been any changes to your address recently? *

Street Address *

Apartment, suite, etc *

City *

State/Province *

ZIP / Postal Code *

Country

Primary Phone Number *

Home Phone Number

Work Phone Number

Best way to contact youPrimaryHomeWork

Has there been any changes to your emergency contact? *

Emergency Contact Full Name *

Emergency Contact Phone Number *

Family Physician *

Person Financially Responsible for the account *SelfSpouseParent/GuardianOther

Preferred Method of Payment *InteractVisaCashMastercard

Has there been any changes to your insurance information? *

Name of Dental Insurance Company *

Name of Policy Holder *

Certificate Number *

Policy Number *

Date of your last dental cleaning *

Are you currently being treated for any medical condition or have you been treated within the past year? *

Please Explain further Details

When was your last medical checkup? *

Has there been any change in your general health in the past year? *

Please Explain further Details

Are you taking any medications, non-prescription drugs or herbal supplements of any kind? *

Please Explain further Details

Do you have any allergies? *

Please list allergies below

Have you ever had a peculiar or adverse reaction to any medicines or injections? *

Please Explain further Details

Do you have or have you ever had asthma? *

Please Explain further Details

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

Please Explain further Details

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? *

Please Explain further Details

Do you have a prosthetic or artificial joint? *

Please Explain further Details

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)? *

Please Explain further Details

Have you ever had hepatitis, jaundice or liver disease? *

Please Explain further Details

Have you ever been hospitalized for any illnesses or operations? *

Please Explain further Details

Do you have or have you ever had any of the following? Please check all that apply. *chest pain, anginarheumatic feverpacemakersteroid therapyseizures (epilepsy)heart attackmitral valve prolapselung diseasediabeteskidney diseasestroke, TIAtuberculosisstomach ulcersthyroid diseaseshortness of breathheart murmurcancerarthritisdrug/alcohol/cannabis use or dependencyosteoporosis medications (e.g. Fosamax, Actonel)None of the above

Are there any conditions or diseases not listed above that you have or have had? *

Please Explain further Details

Do you smoke or use other nicotine products? *

Please Explain further Details

Are you pregnant? *

Expected Due Date ?

Are you breastfeeding? *

Do you have a disability or are a person with visual impairment? *

Please Explain further Details

General Release

Acknowledgment and Consent *I certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.

Date *

Regular dental checkups help in detection of early warning signs of certain health related issues. Visit your dentists regularly and stay healthy.

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