Medical Alert

Name: Mr/Miss/Mrs./Ms. Dr.

Date of Birth (Day/Month/Year):

Address:

City/Postal C

Phone #: HM

Cell

Email:

Who Referred You To Our Office?

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

Name:

Relationship:

Day Time Phone #”:

Name of Medical Specialist:

Area of Speciality:

Phone # or Address:

Name of Family Doctor:

Phone # or Address:

Health Card #:

Pharmacy:

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

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

Yes

No

Not sure/Maybe

If yes, please explain:

When was your last medical checkup?

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

Yes

No

Not sure/Maybe

If yes, please explain:

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

Yes

No

Not sure/Maybe

If yes, please list them:

Do you have any allergies? If yes, please list them using the categories below:

Yes

No

Not sure/Maybe

Medications

Latex/rubber products

Other (e.g., hay fever, seasonal/environmental, foods)

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

Yes

No

Not sure/Maybe

If yes, please explain:

Do you have or have you ever had asthma?

Yes

No

Not sure/Maybe

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

Yes

No

Not sure/Maybe

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

Do you have a prosthetic or artificial joint?

Yes

No

Not sure/Maybe

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

Yes

No

Not sure/Maybe

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

Yes

No

Not sure/Maybe

Do you have a bleeding problem or bleeding disorder?

Yes

No

Not sure/Maybe

Have you ever been hospitalized for any illnesses or operations?

Yes

No

Not sure/Maybe

If yes, please explain:

Do you have or have you ever had any of the following?

Chest pain, angina

Rheumatic fever

Pacemaker

Steroid therapy

Seizures (epilepsy)

Heart attack

Mitral valve prolapse

Lung disease

Diabetes

Kidney disease

Stroke, TIA

Tuberculosis

Stomach ulcers

Thyroid D

Shortness of breath

Heart murmur

Cancer

Arthritis

Drug/alcohol, cannabis use or dependency

Osteoporosis medications (e.g., Fosamax, Actonel)

Hepatitis A/B/C

HIV

High blood pressure

Low blood pressure

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

Yes

No

Not sure/Maybe

If yes, please explain:

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

Yes

No

Not sure/Maybe

Do you smoke or chew tobacco products?

Yes

No

Not sure/Maybe

Are you nervous during dental treatment?

Yes

No

Not sure/Maybe

Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?

Yes

No

Not sure/Maybe

Do you identify as a patient with a disability?

Yes

No

Not sure/Maybe

If yes, please explain:

PATIENT DENTAL HISTORY

Reason for this visit

When was your last dental visit?

What was done then?

How often did you visit the dentist before then?

Previous Dentist (Name and Location)

How often do you brush your teeth?

How often do you floss your teeth?

When was the last time you have had dental x-rays taken?

Do your gums bleed while brushing or flossing?

Yes

No

Are your teeth sensitive to hot or cold?

Yes

No

Are your teeth sensitive to sweet or sore?

Yes

No

Do you feel pain in any of your teeth?

Yes

No

Do you have any sores or lumps in or near your mouth?

Yes

No

Have you had any head, neck, or jaw injuries?

Yes

No

Do you clench or grind your teeth?

Yes

No

Do you have frequent headaches?

Yes

No

Do you bite your lips or cheeks frequently?

Yes

No

Have you noticed any loosening of the teeth?

Yes

No

Does food tend to become caught between your teeth?

Yes

No

Have you ever had periodontal treatment (gums)?

Yes

No

Have you ever worn a bite plate or other appliance?

Yes

No

Have you ever had any difficult extractions in the past?

Yes

No

Have you ever had any prolonged bleeding following extractions?

Yes

No

Do you wear dentures or partials?

Yes

No

If yes, date of placement:

Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Yes

No

Have you ever experienced any of the following problems your jaw:

Clicking

Yes

No

Pain (joint, ear, site of face)

Yes

No

Difficulty in opening or closing

Yes

No

To the best of my knowledge, the above information is correct:

Patient/Parent/Guardian Signature:

Date:

Dentist’s Notes:

Patient’s Medical History Questionnaire