MH

Medical History Form

Please complete the following form and submit online.

Name

Home Phone

Cellphone

Work Phone

Address

City

Province

Postal Code

Date of Birth(MM/DD/Year)

Height

Weight

Emergency Contact Name

Relationship

Emergency Contact Phone Number

How did you hear about our office?

For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

Are you in good health Yes No

Has there been any change in your general health within the past year Yes No

Are you currently under the care of a physician? Yes No

If yes, what is the condition being treated?

Name and address of physician

Name and location of pharmacy

Are you taking any prescription or non- prescription medication? (Please include over the counter or recreational drugs) Yes No

If yes, please list

Have you had any serious illness, operation, or been hospitalized in the past 5 years? Yes No

If yes, please list

Do you have any of the following?

Damaged or artificial heart valve, including murmur or rheumatic heart disease Yes No

Cardiovascular disease (heart trouble, heart attack, angina, coronary insufficiency, Coronary occlusion, arteriosclerosis, stroke) Yes No

High or Low blood pressure Yes No

Do you have a cardiac pacemaker Yes No

Sinus troubles Yes No

Asthma or Hay Fever Yes No

Fainting spells or seizures Yes No

Diabetes Yes No

Hepatitis/Liver Problems Yes No

AIDS/HIV infection Yes No

Thyroid problems Yes No

Respiratory problems, emphysema, bronchitis, etc. Yes No

Arthritis or painful swollen joints Yes No

Stomach ulcer or hyperacidity Yes No

Kidney problems Yes No

Tuberculosis Yes No

Sexually transmitted infection (please list) Yes No

Epilepsy or other neurological disease Yes No

Mental Health concerns Yes No

Cancer Yes No

Problems with immune system Yes No

Have you had abnormal bleeding? Yes No

Do you have any blood disorder such as anemia? Yes No

Have you ever had any treatment for a tumor or growth? Yes No

Are you allergic or have you ever had a reaction to:

Antibiotics Yes No

If yes, please list

Latex Yes No

Other allergies Yes No

If yes, please list

Do you have any disease, condition, or problem not listed above?

Do you use tobacco/cannabis of any type? Yes No

If yes, please list types, how long have you been using

Are you a former tobacco/cannabis user? Yes No

Women

Are you pregnant, or is there a chance you may be pregnant? Yes No

Are you taking birth control pills? Yes No

Are you nursing? Yes No

Dental History

When was your last dental visit?

Is there anything causing you pain or concern in your mouth? Yes No

If yes, please list

Do you currently wear any removable dental appliance? (please list) Yes No

Do you snore or have sleep apnea? Yes No

Do you clench or grind your teeth? Yes No

Are you interested in whitening your teeth? Yes No

Are you interested in straightening your teeth? Yes No

Insurance Information

Please include your insurance details

Insurance Company

Group/Policy #

ID#

Plan Holder Name

Plan Holder Date of Birth(MM/DD/Year)

Secondary Insurance Information

Please include your secondary insurance details

Insurance Company

Group/Policy #

ID#

Plan Holder Name

Plan Holder Date of Birth(MM/DD/Year)

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquires set forth above the have been answered to my satisfaction. I will not hold my dentist, or any other member of his or her staff, responsible for any errors or omissions that I may have made in the completion of this form.