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The care you seek, 6 days a week!

Patient’s Medical History Questionnaire

Medical Alert

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

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

Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
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
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe

PATIENT DENTAL HISTORY

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

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

Yes
No
Yes
No
Yes
No

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

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Info

Westfort Family Dental Office

124 Frederica Street E

Thunder Bay, ON P7E 3V5

Phone: 807-623-3970 

Email: info@westfortdentaloffice.com

Hours

Monday 09:00 AM - 06:00 PM

Tuesday - Saturday 09:00 AM - 05:00 PM

Sunday Closed

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