Medical History Forms
Medical History Form
Date__________________
Name: ___________________________________________________________ Care Card #_____________________________
Date of Birth Y____/M_____/D_____ Male Female Phone: Home. Work
Email address:__________________________________________________
Home address:
City/Province: Postal Code:
Person to notify in case of emergency Relation: Phone
If applicable, name of parent or legally authorized representative__________________________________________________
Occupation _________________________________________
REFFERED BY:
MEDICAL HISTORY QUESTIONNAIRE
Are you a DNR status (do not resuscitate) yes _ No__
Have you ever had a general anesthetic? Yes No If yes, when?
Any complications? Yes No
Any history of familial anesthetic complications? Yes No
Are you being treated for any medical condition at present or within the past two years? Yes No
If yes, please explain.
When was your last visit to a physician? Last complete medical examination?
Have you ever had a serious illness, accident, or required extensive medical care? Yes No If yes, please explain. ___
Have you been hospitalized in the last five years? Yes No If yes, please explain.
Are you taking any prescription or non-prescription drugs? Yes No If yes, what is the drug(s), dose(s), and for how
long?)
Have you ever had a reaction to any drug(s) or been advised against taking any kind of medication? Yes No
If yes, please explain.
Do you have any sensitivities or allergies? Yes No If yes, please explain.
Do you have any history of family disease? Yes No If yes, please explain.
Indicate which of the following you presently have or ever had.
Yes No Yes No Yes No
Fainting or dizzy spells....... Hyper(hypo) glycemia ...... Psychiatric treatment ........
Glandular disorders ............ Hypertension .................... Radiation treatment
Glaucoma .......................... Impaired vision ................ chemotherapy................
Headaches (severe) ............ Infective endocarditis ....... Rheumatic/scarlet fever .....
Head/neck injuries.............. Jaundice .......................... Shortness of breath ...........
Hearing difficulties ............ Kidney disease.................. Sickle cell disease .............
Heart disease or attack ...... Leukemia ......................... Sinus trouble.....................
Heart murmur.................... Liver disease .................... Stomach/intestinal
Heart pacemaker ............... Lung disease .................... problems ...........................
Heart rhythm disorder........ Malignant hyperthermia ... Stroke...............................
Heart surgery..................... Medical implant ............... Temperature intolerance ...
Hemophilia ........................ Mental/nervous disorder ... Thyroid disease .................
Hepatitis A ........................ Mitral valve prolapse........ Tuberculosis......................
Hepatitis B ........................ Nosebleeds (frequent)....... Ulcers ...............................
Hepatitis C......................... Organ transplant .............. Venereal disease................
Herpes ............................... Persistent cough............... Weight gain/loss................
High/low blood pressure ..... Pulmonary edema ............ Asthma ................................
Hodgkin’s disease............... Positive testing for HIV.... Sleep Apnea...........................
Do you smoke or use other forms of tobacco? Yes No
Do you have a history of alcohol and/or drug use? Yes No
Have you received treatment for alcohol or drug use?` Yes No
Do you currently have, or have you had in the past, any disease, condition or problem not listed? Yes No
If yes, please explain.
Is there any problem or medical condition that you wish to discuss in private only? Yes No
WOMEN ONLY: Are you pregnant or suspect you might be? Yes No Anticipated delivery date?
Are you breast feeding? Yes No
Are you taking any birth control pills? Yes No
NOTE: IT IS IMPORTANT THAT ANY CHANGES IN YOUR
HEALTH STATUS BE REPORTED TO OUR OFFICE.
I, the undersigned, certify that all of the medical and dental information provided is true to the best of my knowledge, and I
have not knowingly omitted any information. I also consent to my physician being contacted if necessary to obtain information that is required for my dental care.
Signature Date
Patient Parent Legally Authorized Representative
Reviewed by Surgeon Date
