647-828-8000
info@dentistryatsheppard.com
2048 Sheppard Ave E, North York
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Medical History Questionnaire
Medical History Questionnaire
Medical History Questionnaire
Name
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In Case of Emergency Notify:
Date of Birth:
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Relationship:
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Day-Time Phone
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Family Doctor
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Referred By
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 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
Why?
2. When was your last medical checkup?
3. Has there been any changes in your general health in the past year? If yes, please explain:
Yes
Yes
No
Not Sure
4. Are you taking any medications, non-prescriptive drugs, or herbal supplements of any kind?
Yes
No
Not Sure
5. Do you have any allergies? If yes, please list using the categories below.
Yes
No
Not Sure
a) Medications:
b) Latex / Rubber products:
c) Other e.g., hay fever, foods:
6. Have you ever had a peculiar or adverse reaction to any medications or injections? If yes, please explain:
Yes
Yes
No
Not Sure
7. Do you or have you ever had asthma?
Yes
No
Not Sure
8. Do you or have you ever had a heart murmur, mitral valve prolapses or rheumatic fever?
Yes
No
Not Sure
9. Do you or have you ever had any heart or blood pressure problems?
Yes
No
Not Sure
10. Do you have a prosthetic or artificial joint?
Yes
No
Not Sure
11. Have you ever been advised by your doctor to take antibiotics before dental treatment?
Yes
No
Not Sure
12. 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
13. Have you ever had hepatitis, jaundice, or liver disease?
Yes
No
Not Sure
14. Do you have a bleeding problem or disorder?
Yes
No
Not Sure
15. Have you ever been hospitalized for any illness or operations? If yes please explain.
Yes
Yes
No
Not Sure
16. Do you or have you ever had any of the follow?? Please check.
Chest pain
Shortness of breath
Steroid therapy
Seizures epilepsy
Drug/alcohol dependency
Heart attack
Lung disease
Diabetes
Kidney disease
Thyroid disease
Stroke
Cancer
Arthritis
Tuberculosis
Stomach ulcers
Diet pill therapy
Prosthetic heart valve
17. Are there any conditions or disease not listed above that you have or have had? If so, what?
Yes
No
Not Sure
What?
18. Are there diseases or medical problems that run in your family?(e.g. diabetes, cancer or heart disease)
Yes
No
Not Sure
19. Do you smoke or chew tobacco?
Yes
No
Not Sure
20. Are you nervous during dental treatment?
Yes
No
Not Sure
21. For women only: Are you pregnant or breast feeding? If pregnant, what is the expected delivery date?
Yes
No
Not Sure
what is the expected delivery date?
22. Do you use cannabis?
Yes
No
Not Sure
23. If yes, for what purpose do you use cannabis?
Medical
Recreational
Both
24. For what medical condition do you use cannabis?
25. How do you usually take cannabis?
Smoke
Vape
Ingest
26. Have you ever had any side effects with your cannabis use? If yes, what type of side effects?
No
Yes
Yes
27. When did you last use cannabis?
28. In addition to cannabis, do you use any other recreational drugs?
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