Medical Form

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MEDICAL HISTORY QUESTIONNAIRE

 

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.

1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why?
YESNONOT SURE/MAYBE

2. When was your last medical checkup?
3. Has there been any change in your general health in the past year? If yes, please explain.
YESNONOT SURE/MAYBE

4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list.
YESNONOT SURE/MAYBE

5. Do you have any allergies? If you answered yes, please list from the following:
a) Medications
b) Latex/rubber products
c) Other (e.g. hayfever, foods)
YESNONOT SURE/MAYBE

6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.
YESNONOT SURE/MAYBE

7. Do you have or have you ever had asthma?
YESNONOT SURE/MAYBE

8. Do you have or have you ever had any heart or blood pressure problems?
YESNONOT SURE/MAYBE

9. 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?
YESNONOT SURE/MAYBE

10. Do you have a prosthetic or artificial joint?
YESNONOT SURE/MAYBE

11. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?
YESNONOT SURE/MAYBE

12. Have you ever had hepatitis, jaundice or liver disease?
YESNONOT SURE/MAYBE

13. Do you have a bleeding problem or bleeding disorder?
YESNONOT SURE/MAYBE

14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
YESNONOT SURE/MAYBE

15. Do you have or have you ever had any of the following? Please check.
chest pain, anginaheart attackstrokeshortness of breathrheumatic fevermitral valve prolapseheart murmurpacemakerlung diseasetuberculosiscancersteroid therapydiabetesstomach ulcersarthritisseizures (epilepsy)kidney diseasethyroid diseasedrug/alcohol dependencyosteoporosis medications (e.g. Fosamax, Actonel)

16. Are there any conditions or diseases not listed above that you have or have had? If so, what?
YESNONOT SURE/MAYBE

17. Are there any diseases or medical problems that run in your family?
(e.g. diabetes, cancer or heart disease?
YESNONOT SURE/MAYBE

18. Do you smoke or chew tobacco products?
YESNONOT SURE/MAYBE

19. Are you nervous during dental treatment?
YESNONOT SURE/MAYBE

20. For women only: Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?
YESNONOT SURE/MAYBE

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

 

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