Information & Medical History

Title *

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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Phone Number *

Please enter a valid phone number.

Email *

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Occupation *

Who referred you to our Office?

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

Name

First

Last

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Relationship

Phone Number

Please enter a valid phone number.

Name of Family Doctor *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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Name of Medical Specialist

Area of Specialty

Phone Number

Please enter a valid phone number.

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Medical History

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.

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When was your last medical check-up? *

Date

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Has there been any change in your general health in the past year? If yes, please explain. *

Yes
No
Not Sure/Maybe

If yes, please explain

1

1. hospitalization for illness or injur

YES/NO

Yes
No

2

3

3. heart problems, or cardiac stent within the last six month

YES/NO

Yes
No

4

4. history of infective endocarditis

YES/NO

Yes
No

5

5. artificial heart valve, repaired heart defect (PFO)

YES/NO

Yes
No

6

6. pacemaker or implantable defibrillator

YES/NO

Yes
No

7

7. orthopedic or soft tissue implant(e.g joint replacement, breast implant)

YES/NO

Yes
No

8

8. heart murmur, rheumatic or scarlet fever

YES/NO

Yes
No

9

9. high or low blood pressure

YES/NO

Yes
No

10

10. a stroke (taking blood thinners)

YES/NO

Yes
No

11

11. anemia or other blood disorder

YES/NO

Yes
No

12

12. prolonged bleeding due to a slight cut (or INR > 3.5

YES/NO

Yes
No

13

13. pneumonia, emphysema, shortness of breath, sarcoidosis

YES/NO

Yes
No

14

14. chronic ear infections, tuberculosis, measles, chicken pox

YES/NO

Yes
No

15

15. breathing problems (e.g. asthma, stuffy nose, sinus congestion)

YES/NO

Yes
No

16

16. sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)

YES/NO

Yes
No

17

17. kidney disease

YES/NO

Yes
No

18

18. liver disease or jaundice

YES/NO

Yes
No

19

19. vertigo (e.g. ”the room is spinning”)

YES/NO

Yes
No

20

20. thyroid, parathyroid disease, or calcium deficiency

YES/NO

Yes
No

21

21. hormone deficiency or imbalance(e.g. poly cystic ovarian syndrome)

YES/NO

Yes
No

22

22. high cholesterol or taking statin drugs

YES/NO

Yes
No

23

23. diabetes (HbA1c = ___________ )

YES/NO

Yes
No

24

24. stomach or duodenal ulcer

YES/NO

Yes
No

25

25. digestive or eating disorders(e.g. celiac disease, gastric reflux, bulimia, anorexia)

YES/NO

Yes
No

26

26. osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)

YES/NO

Yes
No

27

27. arthritis or gout

YES/NO

Yes
No

28

28. autoimmune disease

(e.g. rheumatoid arthritis, lupus, scleroderma)

YES/NO

Yes
No

29

29. glaucoma

YES/NO

Yes
No

30

30. contact lenses

YES/NO

Yes
No

31

31. head or neck injuries

YES/NO

Yes
No

32

32. epilepsy, convulsions (seizures)

YES/NO

Yes
No

33

33. neurologic disorders

(e.g. Alzheimer’s disease, dementia, prion disease)

YES/NO

Yes
No

34

34. viral infections and cold sores

YES/NO

Yes
No

35

35. any lumps or swelling in the mouth

YES/NO

Yes
No

36

36. hives, skin rash, hay fever

YES/NO

Yes
No

37

37. STI/STD/HPV

YES/NO

Yes
No

38

38. hepatitis (type______________ )

YES/NO

Yes
No

39

39. HIV/AIDS

YES/NO

Yes
No

40

40. tumor, abnormal growth

YES/NO

Yes
No

41

41. radiation therapy

YES/NO

Yes
No

42

42. chemotherapy, immunosuppressive medication

YES/NO

Yes
No

43

43. emotional difficulties

YES/NO

Yes
No

44

44. psychiatric treatment or antidepressant medication

YES/NO

Yes
No

45

45. concentration problems or ADD/ADHD

YES/NO

Yes
No

46

46. alcohol/recreational drug use

YES/NO

Yes
No

ARE YOU:

47

47. presently being treated for any other illness

YES/NO

Yes
No

48

48. aware of a change in your health in the last 24 hours

(e.g., fever, chills, new cough, or diarrhea)

YES/NO

Yes
No

49

49. taking medication for weight management

YES/NO

Yes
No

50

50. taking dietary supplements, vitamins, and/or probiotics

YES/NO

Yes
No

51

51. often exhausted or fatigued

YES/NO

Yes
No

52

52. experiencing frequent headaches or chronic pain

YES/NO

Yes
No

53

53. a smoker, smoked previously or other

(e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis)

YES/NO

Yes
No

54

54. considered a touchy/sensitive person

YES/NO

Yes
No

55

55. often unhappy or depressed

YES/NO

Yes
No

56

56. taking birth control pills

YES/NO

Yes
No

57

57. currently pregnant

YES/NO

Yes
No

58

58. diagnosed with a prostate disorder

YES/NO

Yes
No

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Patient Signature *

Digital Signature

Date *

Information & Medical History

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

Medical History

ARE YOU:

Request an Appointment

2. What is the reason you need a dental visit?

6. Describe the situation that the doctor should be aware of?

10. When would be a good time for our staff to reach you and confirm the appointment?