Medical History Form Patient Information Patient Name What is your estimate of your general health? GoodFairExcellentPoor Nickname Age Family Physician’s Name Most recent exam NEXT Allergies Aspirin, ibuprofen, acetaminophen, codeine YesNo Penicillin YesNo Erythromycin YesNo Local Anesthetic YesNo Sulpha YesNo Tetracycline YesNo Fluoride YesNo Metals (nickel, gold, silver) YesNo Latex YesNo Other (Please specify) BackNext Medical History: DO YOU HAVE or HAVE YOU EVER HAD: Hospitalization for illness or injury YesNo Heart problems/cardiac stent within the last 6 months YesNo History of infective endocarditis YesNo Artificial heart valve, repaired heart defect (PFO) YesNo Pacemaker or implantable defibrillator YesNo Rheumatic or scarlet fever YesNo High or low blood pressure YesNo A stroke (taking blood thinners) YesNo Anemia or other blood disorder YesNo Prolonged bleeding due to a slight cut (INR > 3.5) YesNo Emphysema, sarcoidosis YesNo Tuberculosis YesNo Asthma YesNo Breathing or sleep problems (i.e., snoring, sinus) YesNo Kidney disease YesNo Liver disease YesNo Jaundice YesNo Thyroid, parathyroid disease, calcium deficiency YesNo Hormone deficiency YesNo High cholesterol or taking statin drugs YesNo Diabetes (HbA1c=__) YesNo Stomach or duodenal ulcer YesNo Digestive disorders (i.e., gastric reflux) YesNo Osteoporosis/osteopenia (i.e., taking bisphosphonates) YesNo Arthritis YesNo Glaucoma YesNo Contact lenses YesNo Head or neck injuries YesNo Epilepsy/convulsions (seizures) YesNo Neurologic problems YesNo Viral infections and cold sores YesNo Any lumps or swelling in the mouth YesNo Hives, skin rash, hay fever YesNo Venereal disease YesNo Hepatitis (type _____) YesNo HIV/AIDS YesNo Tumor/abnormal growth YesNo Radiation therapy YesNo Chemotherapy YesNo Emotional problems YesNo Psychiatric treatment YesNo Antidepressant medication YesNo Alcohol or drug dependency YesNo Dizziness YesNo Fainting YesNo Have you ever experienced complications following a medical or dental procedure? YesNo Has your physician ever told you to take antibiotics prior to dental procedures? YesNo Have you ever had joint replacement? If yes, when/which YesNo BackNext ARE YOU: Presently being treated for any illness? YesNo Aware of a change in your general health? YesNo Taking medication for weight management? YesNo Taking dietary supplements? YesNo Often exhausted or fatigued? YesNo Subject to frequent headaches? YesNo A smoker or smoked previously? YesNo Considered a touchy person? YesNo Often unhappy or depressed? YesNo For Female Patients Are you taking birth control pills? YesNo Are you pregnant? YesNo Are you breastfeeding? YesNo For Male Patients Do you have prostate disorders? YesNo BackNext Current Medical Treatment Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment Medications List all medications, supplements, and/or vitamins taken within the last two years Consent Patient’s Signature Doctor’s Signature Date Back New Patient Form Patient Information Title MrMrsMissDr First Name Last Name Date of Birth Gender MaleFemale Preferred Name Address City Province Postal Code Phone Number Phone Type HomeCellWork Extension (if applicable) Email Address NEXT Emergency Contact Name Relationship to Patient Phone Number Referral Information How did you hear about us? Friend/RelativeInternetWebsiteOther If Friend/Relative, please specify their name: Additional Information Marital Status MarriedSingleDivorcedWidowed Employment Status Full TimePart TimeUnemployedRetiredStudent For Minors If the patient is a minor (under 18), please provide Parent/Legal Guardian Information Parent/Legal Guardian Name Parent/Legal Guardian Phone Number BackNext Dental History Check any of the following problems that may apply to you: Sensitive teethJaw joint pain (clicking)Bleeding, swollen gumsLoose/poor fitting denturesTeeth or filling breakingLoose or shifting teethMissing teeth/spacesTooth pain or discomfortHeadaches, earaches, neck painGrinding or clenching teethBad breath or bad taste in mouthPrevious orthodontics or gum surgery Last Dental Cleaning Last Dental Visit Last X-Rays Dental Visit Concerns Are you anxious during dental visits? YesNo Have you ever had an unfavorable reaction during dental treatment? YesNo Have you ever had complications after extraction? YesNo Have you ever had orthodontic treatment? YesNo Have you ever smoked? YesNo Do you currently smoke? YesNo Overall Dental Health How would you describe your dental health at present? GoodFairExcellentPoor Back
