Medical History Form

Laurier Dental
500 Laurier Avenue, Milton, Ontario L9T 4R3 (905) 878-9882
MEDICAL HISTORY QUESTIONNAIRE
MEDICAL ALERT:
NAME: MR./MISS/MRS./MS./DR.
DATE OF BIRTH (DAY/MONTH/YEAR)

Month Day Year
Date
ADDRESS (HOME)
CITY
POSTAL CODE
PHONE
OCCUPATION
BUSINESS PHONE
CELL PHONE
E-MAIL
example@example.com
WHO REFERRED YOU TO OUR OFFICE?
IN CASE OF EMERGENCY, WE SHOULD NOTIFY:
NAME
RELATIONSHIP
DAY-TIME PHONE
NAME OF FAMILY DOCTOR
PHONE
OHIP #
NAME OF MEDICAL SPECIALIST
AREA OF SPECIALITY
PHONE OR ADDRESS
INSURANCE INFORMATION
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?

YES NO NOT SURE/MAYBE
If so, why?
2. When was your last medical checkup?
3. Has there been any change in your general health in the past year?

YES NO NOT SURE/MAYBE
If yes, please explain.
4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

YES NO NOT SURE/MAYBE
If yes, please list.
5. Do you have any allergies? If you answered yes, please list using the categories below: a) medications b) latex/rubber products c) other (e.g., hayfever, foods)4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

YES NO NOT SURE/MAYBE
If yes, please list.
6. Have you ever had a peculiar or adverse reaction to any medications or injections?

YES NO NOT SURE
If yes, please explain.
7. Do you have or have you ever had asthma?

YES NO NOT SURE
If yes, please explain.
8. Do you have or have you ever had any heart or blood pressure problems?

YES NO NOT SURE/MAYBE
If yes, please explain.
9. Do you have or have you ever had an artificial 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
If yes, please explain.
10. Do you have a prosthetic or artificial joint?

YES NO NOT SURE/MAYBE
If yes, please explain.
11. 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
If yes, please explain.
12. Have you ever had hepatitis, jaundice or liver disease?

YES NO NOT SURE/MAYBE
If yes, please explain.
13. Do you have a bleeding problem or bleeding disorder?

YES NO NOT SURE/MAYBE
If yes, please explain.
14. Have you ever been hospitalized for any illnesses or operations?

YES NO NOT SURE/MAYBE
If yes, please explain.
15. Do you have or have you ever had any of the following? Please check.

chest pain, angina rheumatic fever lung disease diabetes kidney disease osteoporosis medications (e.g., Fosamax, Actonel) heart attack mitral valve prolapse tuberculosis stomach ulcers thyroid disease stroke heart murmur cancer arthritis drug/alcohol dependency shortness of breath pacemaker steroid therapy seizures (epilepsy)
16. Are there any conditions or diseases not listed above that you have or have had?

YES NO NOT SURE/MAYBE
If so, what?
17. Are there any diseases or medical problems that run in your family? (e.g., diabetes, cancer or heart disease)

YES NO NOT SURE/MAYBE
If yes, please explain.
18. Do you smoke or chew tobacco products?

YES NO NOT SURE/MAYBE
If yes, please explain.
19. Are you nervous during dental treatment?

YES NO NOT SURE/MAYBE
If yes, please explain.
20. For women only: Are you breastfeeding or pregnant?

YES NO NOT SURE/MAYBE
If pregnant, what is the expected delivery date?
I, the undersigned, acknowledge that I have provided an accurate personal medical/dental history. I will inform you if there are any changes in my health or medications at future appointments. Dr. Summer Al Maqdassy or her staff may contact my physician, if necessary, to discuss any relevant medical information. I, the undersigned, consent to the performing of dental procedures, x-rays, and diagnostic tests agreed to be necessary or advisable for this case.
Patient's (Parent's) Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Laurier Dental

MEDICAL HISTORY QUESTIONNAIRE

MEDICAL ALERT:

IN CASE OF EMERGENCY, WE SHOULD NOTIFY: