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.

1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why?

Yes No Not sure
Yes
No
Not sure

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

4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

+
Yes
No
Not sure

5. Do you have any allergies?

+
Yes
No
Not sure

6. Have you ever had a peculiar or adverse reaction to any medicines or injections?

Yes
No
Not sure

7. Do you have or have you ever had asthma?

Yes
No
Not sure

8. Do you have or have you ever had any heart or blood pressure problems?

Yes
No
Not sure

9. Do you have or have you ever had a replacement or repair of a 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

10. Do you have a prosthetic or artificial joint?

Yes
No
Not sure

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

12. Have you ever had hepatitis, jaundice or liver disease?

Yes
No
Not sure

13. Do you have a bleeding problem or bleeding disorder?

Yes
No
Not sure

14. Have you ever been hospitalized for any illnesses or operations?

Yes
No
Not sure

15. Do you have or have you ever had any of the following? Please check.

Yes
No
Not sure

16. Are there any conditions or diseases not listed above that you have or have had?

+
Yes
No
Not sure

17. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)

+
Yes
No
Not sure

18. Do you smoke or chew tobacco products?

Yes
No
Not sure

19. For women only: Are you breastfeeding or pregnant?

Yes
No
Not sure

Contact us today to set up your free consultation, and make the move to a happier and healthier smile.

Call Us: 416-238-5859
or

Make an Appointment Online

Contact us for details

Contact us for details