Dentistry on 14 | Medical History Form | Dentistry on 14
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Medical History Form

First name

Last Name

Address

Street/Apartment

City

Prov

Postal Code

Date of Birth

Home Tel

Email ID

In case of emergency, We should notify your:

First name

Last Name

Relationship

PH

Family Docter

PH

Personal Information:

MEDICAL INFORMATION & HISTORY:

Dental professionals primarily treat the area in and around your mouth. Since your mouth is a part of your body; any medications that you are
taking and your medical history as well, both have an important relationship with your dental treatment. Please answer the following questions.

Are you currently under the care of a physician:

Last Visit:

Reason:

Please review the section below and tick/select all those that apply to you. Please further indicate anything that may not be listed. Your information is for our records only and will be kept confidential and handled in accordance with privacy laws.


































































For women only: Are you taking any birth control pills?:

Are you, or could you be pregnant?:

If YES, what is the expected delivery date?

FOR CHILDREN ONLY:- Have you recently had any of following(Approximate date)




List of current Medications and Prescriptions/Non-Prescription Drugs:

Are you taking any Blood thinners:

Do you bruise easily or have prolonged bleeding?

Are you taking anything for your bones/osteoporosis:

Bisphosphonates:

Other:

Please list any medications which you may have been advised against:

Please indicate any other allergic conditions, or other conditions in general. This can include asthma, hay-fever, food allergies, and metal or latex allergies:

Have you ever had any joint replacement surgery?

Have you been told by your doctor that you need to take pre-medication (i.e. antibiotics) one hour before your dental appointments?

Do you smoke cigarettes?

Please indicate any recreational drugs :

Have you ever had a heart surgery, including heart valve replacement, heart transplant or repair?

Have you ever have been hospitalized in the past two years?

DENTAL INFORMATION:

Please review the section below and check all those that apply to you. Please further indicate anything that may not be listed. Your information is for our records only and will be kept confidential and handled in accordance with privacy laws.

Do your gums bleed during brushing or flossing ?

Have you ever had Orthodontic Treatment?

Are your teeth sensitive to cold, hot, sweets, or pressure?

Do you feel pain in any of your teeth?

Have you ever had a head, neck, or jaw injury?

Do you have any loose teeth, or have they ever shifter?

Have you had any pain in your jaw area?

Do you bite your lip or cheeks frequently?

Does food frequently get caught in your teeth?

Have you ever had difficulty opening or closing your jaw?

Do you have any headache or migraine?

Ever worn a bite plate or other appliance?

Do you have any sores or lumps in or near your mouth?

Have you ever had periodontal/gum Treatment ?

Last Dental Visit:

Last Cleaning:

Last radiographs:

Do you have any emotional concerns regarding dental treatment:

FINANCIAL INFORMATION:

Person responsible for financial matters:

This account will be paid by:

Insurance information:-

Insurance company:

Certificate no.:

Full Name:

Policy no.:

Subscriber name:

Address:

Postal Code:

Date of birth:

Home Tel:

GENERAL RELEASE:

I , understand that the information contained in the dental and medical history portion of this chart is important to my treatment. I certify that all the information is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health provider as is required by this dental office to perform diagnostic procedures as may be required to determine necessary reatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

Since phase 2, and having reopened our office, we couldn't be happier to be connecting with our patients! We are taking the utmost precautions to provide a safe Covid free environment. Face shields, air purifiers, and limiting the number of patients to those that have appointments are just some of the new policies we have implemented. After every set of patients, we're dedicating time to properly sanitize the rooms, instruments and the waiting area, to ensure safety for the next set of patients. Please call us today for a free consultation!
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