Medical history questionnaire



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MEDICAL HISTORY QUESTIONNAIRE
In order to give you the best dental care, we require the client information below. All information is strictly confidential. Some questions may seem unimportant for this visit, but may be vital in case of emergency so please answer every question. Please feel free to ask for help.

1. PERSONAL HISTORY

Client Name:




Home Address:




Date of Birth:










Marital Status:

 Single  Married  Other

Name of Partner/Spouse:




Occupation:




Employer Name:




Home Phone:




Work Phone:




Students:

Mother’s Name:




Father’s Name:




Do you have dental insurance?

 Yes  No

Insurance Company:




2. MEDICAL HISTORY

Name of Family Doctor:




  1. To the best of your knowledge, are you in good health?

 Yes  No

  1. Have you ever had a serious illness or are you under a doctor’s care?

 Yes  No

  1. Have you seen a doctor in the past year?

 Yes  No

  1. Are you taking any medications at the present time?
    If yes, please list: _____________________________________

 Yes  No

  1. Have you ever had a heart murmur?

 Yes  No

  1. Do you have any allergies (especially drugs or anaesthetic)?
    If yes, please list: _____________________________________

 Yes  No

  1. Do you smoke or use tobacco products?

 Yes  No

  1. Have you ever had any major surgery?

 Yes  No

  1. Women only: Are you pregnant? If yes, how many weeks?

 Yes  No

  1. Have you ever had or been treated for any of the following? Please check each:
     Strep Throat  Heart Trouble  Stroke  Asthma  Nervous Disorder
     Hay Fever  Liver Disease  Skin Rash Cancer  Bruising Easily
     Jaundice  Blood Disorder  Chest Pain  HIV  High Blood Pressure
     Epilepsy  Thyroid Disease  Diabetes  Hives  Shortness of Breath
     Hepatitis  Face Injury  Kidney Disease  Jaw Injury  Bleeding Disorder
     Other: (please list) _________________________________________________________________

3. DENTAL HISTORY



What dental condition (if any) concerns you at present?












When was your last dental visit?






Have you ever had ill effects from freezing (local anaesthetic)?

 Yes  No

I hereby consent to the dental and oral surgery procedures agreed to be necessary or advisable for myself or child, including the use of local anaesthesia and/or relative analgesia.













Signature




Date


Revised: March 13, 2013
Personal information is collected under the authority of the Health Protection and Promotion Act and related legislation and in accordance with the Personal Health Information Protection Act and/or the (Municipal) Freedom of Information and Protection of Privacy Act. We collect only the personal information needed to provide public health programs and to plan and evaluate our services. Your information may be shared with others as required or permitted by law. For more information contact Northwestern Health Unit at 1-800-830-5978 or see the privacy statement on our web-site at www.nwhu.on.ca


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