Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Who referred you to our office?
Occupation
Name
First Name
Last Name
Relationship
Day Time Phone
(###)
###
####
Name of Family Doctor
First Name
Last Name
Phone or Address
Name of Medical Specialist & Phone or Address
Are you being treated for any medical condition at the present or have you been treated within the past year? If so why?
*
If so, why?
When was your last medical checkup?
Has there been any change in your general health in the past year?
If yes, please explain.
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
If yes, please list.
Do you have allergies?
If you answer yes, please list using the categories below:
Medications
Latex/Rubber products
Other (e.g. hayfever, foods)
Have you ever had a peculiar or adverse reaction to any medicines or injections?
If yes, please explain.
Do you have or have you ever had asthma?
If so, when were you diagnosed and what triggers your asthma? Have you ever been hospitalized for breathing problems?
Do you have or have you ever had any heart or blood pressure problems?
If so, when were these problems diagnosed? Are you taking medications for your heart or blood pressure? Have you been hospitalized?
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (ie. infective endocarditis), a heart condition from birth (ie. congenital heart disease) or a heart transplant?
If so, please describe.
Do you have a prosthetic or artificial joint?
If so, please describe. Were you told to take antibiotics before dental treatment?
Do you have any conditions or therapies that could affect your immune system, eg. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?
If so, please describe.
Have you ever had hepatitis, jaundice or liver disease?
If so, please explain.
Do you have a bleeding problem or bleeding disorder?
If so, please explain.
Have you ever been hospitalized for any illnesses or operations?
If yes, please explain.
Do you have or have you ever had any of the following?
Please Check
Are there any conditions or diseases not listed above that you have or have had?
If so, what?
Are there any diseases or medical problems that run in your family? (eg. diabetes, cancer or heart disease)
If so, what?
Do you smoke or chew tobacco products?
If so, what products?
Are you nervous during dental treatment?
Please rate your response to the following statements:
I am fearful of coming to the dental office and receiving dental treatment.
If so, please describe why (if possible)
FOR WOMEN ONLY. Are you breastfeeding or pregnant?
If pregnant, what is the expected delivery date?
