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Dentistry @ Erin Mills

2180 Credit Valley Rd, Unit 106A, Mississauga, ON L5M 3C9

Medical History Questionnaire
Patient Consent Form

Medical History Questionnaire Form

Name *

Date Of Birth *

Address ( Home) *

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone: *

How did you hear about us?

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

Name *

Relationship *

Day-Time Phone *

Name of Family Doctor

Phone Or Address

(1) Name OF Medical Specialist

Area of Specialty

Phone Or Address

(2) Name OF Medical Specialist

Area of Specialty

Phone Or Address

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.

Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain? *

Yes
No
Not Sure/Maybe

Treatment Details:

When was your last medical checkup? *

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

Yes
No
Not Sure/Maybe

Please Explain

Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list them. *

Yes
No
Not Sure/Maybe

Medication

Do you have any allergies? If yes, please list them using the categories below: *

Yes
No
Not Sure/Maybe

Allergies Types

Medications
Latex/rubber products
Other (e.g. hay fever, seasonal/environmental, foods)

Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain. *

Yes
No
Not Sure/Maybe

Explain the adverse reaction

Do you have or have you ever had asthma? *

Yes
No
Not Sure/Maybe

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/Maybe

Do you have a prosthetic or artificial joint? *

Yes
No
Not Sure/Maybe

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/Maybe

Have you ever had hepatitis, jaundice or liver disease? *

Yes
No
Not Sure/Maybe

Do you have a bleeding problem or bleeding disorder? *

Yes
No
Not Sure/Maybe

Have you ever been hospitalized for any illnesses or operations? If yes, please explain. *

Yes
No
Not Sure/Maybe

Hospitalization

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

chest pain, angina
rheumatic fever
pacemaker
steroid therapy
seizures (epilepsy)
heart attack
mitral valve prolapse
lung disease
diabetes
kidney disease
stroke, TIA
tuberculosis
stomach ulcers
thyroid disease
shortness of breath
heart murmur
cancer
arthritis
drug/alcohol/cannabis use or dependency
osteoporosis medications (e.g. Fosamax, Actonel)
None

Are there any conditions or diseases not listed above that you have or have had? If yes, please explain. *

Yes
No
Not Sure/Maybe

Diseases explanation

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

Yes
No
Not Sure/Maybe

Are you nervous during dental treatment? *

Yes
No
Not Sure/Maybe

Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?

Yes
No
Not Sure/Maybe

Expected delivery date

Do you identify as a patient with a disability? If yes, please explain. *

Yes
No
Not Sure/Maybe

Explain

Insurance Information

Do you have extended health or dental insurance? *

Yes
No

If yes, Please provide your card to receptionist, they will make a copy of your file. *

Dental History

What is the reason of your visit today?

When was your last Dental visit?

Are you teeth sensitive to: *

Cold
Sweet
Heat
Other
Never

Describe Sensitivity *

Do your gums bleed when: *

Brushing
Flossing
Never

Do your gums feel swollen or tender? *

Yes
No

Do you have bad breath or bad taste in your mouth? *

Yes
No

Do you have food catch in your teeth? *

Yes
No

Do you ever had local anesthetic (freezing) *

Yes
No

If Yes, were there any complications? ( Please specify) *

Have you had any problems with previous dental treatments? *

Yes
No

If yes, then please specify *

Have you had any of the following?

Bridgework
Crowns or Caps
Full or Partial Denture
Orthodontic( Braces)
Periodontal (Gums)
Root Canal
None

Are you satisfied with your teeth? *

Yes
No

Do you have Sleep Apnea? *

Yes
No

If Yes, are you using any of the following?

CPAP machine
Oral Appliance

To the best of my knowledge, the above information is correct:

Name *

Date *

Patient/Parent/Guardian Signature: *

Clear Signature