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Medical History Form
8321 KENNEDY RD. UNIT # 22. MARKHAM, L3R 5N4
905.470.4289
MEDICAL HISTORY QUESTIONNAIRE
MEDICAL ALERT:
FULL NAME
DATE OF BIRTH (DAY/MONTH/YEAR)
ADDRESS (HOME)
CITY
POSTAL CODE
PHONE
OCCUPATION
BUSINESS PHONE
CELL PHONE
E-MAIL
WHO REFERRED YOU TO OUR OFFICE?
IN CASE OF EMERGENCY, WE SHOULD NOTIFY:
NAME
RELATIONSHIP
DAY-TIME PHONE
NAME OF FAMILY DOCTOR
PHONE
OHIP #
NAME OF MEDICAL SPECIALIST
AREA OF SPECIALITY
PHONE OR ADDRESS
INSURANCE INFORMATION
Are you being treated for any medical condition at the present or have you been treated within the past year?
yes
no
Not Sure/Maybe
If so, why?
When was your last medical checkup?
Has there been any change in your general health in the past year?
yes
no
Not Sure/Maybe
If yes, please explain.
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
yes
no
Not Sure/Maybe
If yes, please list.
Do you have any allergies? If you answered yes, please list using the categories below: a) medications b) latex/rubber products c) other (e.g., hayfever, foods)4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
yes
no
Not Sure/Maybe
If yes, please list.
Have you ever had a peculiar or adverse reaction to any medications or injections?
yes
no
Not Sure/Maybe
If yes, please explain.
Do you have or have you ever had any heart or blood pressure problems?
yes
no
Not Sure/Maybe
If yes, please explain.
Do you have or have you ever had asthma?
yes
no
Not Sure/Maybe
If yes, please explain.
Do you have or have you ever had any heart or blood pressure problems?
yes
no
Not Sure/Maybe
If yes, please explain.
Do you have or have you ever had an artificial 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
If yes, please explain.
Do you have a prosthetic or artificial joint?
yes
no
Not Sure/Maybe
If yes, please explain.
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
If yes, please explain.
Have you ever had hepatitis, jaundice or liver disease?
yes
no
Not Sure/Maybe
If yes, please explain.
Do you have a bleeding problem or bleeding disorder?
yes
no
Not Sure/Maybe
If yes, please explain.
I Have you ever been hospitalized for any illnesses or operations?
yes
no
Not Sure/Maybe
If yes, please explain.
Do you have or have you ever had any of the following? Please check.
chesr pain,angaina
eheumatic fever
lung disease
diabetes
kidney disease
osteoporosis
heart attack
mitral valve prolapse
tuberculosis
stomach
stomach ulcers
thyroid dusease
strok
heart murmur
cancer
arthritis drug/alcohol dependency
shortness of breath
pacemaker
steroid theraypy
seizures (epilepsy)
Are there any conditions or diseases not listed above that you have or have had?
yes
no
Not Sure/Maybe
If so, what?
Are there any diseases or medical problems that run in your family? (e.g., diabetes, cancer or heart disease)
yes
no
Not Sure/Maybe
If yes, please explain.
Are you nervous during dental treatment?
yes
no
Not Sure/Maybe
If yes, please explain.
For women only: Are you breastfeeding or pregnant?
yes
no
Not Sure/Maybe
If pregnant, what is the expected delivery date?
I, the undersigned, acknowledge that I have provided an accurate personal medical/dental history. I will inform you if there are any changes in my health or medications at future appointments. Dr. Summer Al Maqdassy or her staff may contact my physician, if necessary, to discuss any relevant medical information. I, the undersigned, consent to the performing of dental procedures, x-rays, and diagnostic tests agreed to be necessary or advisable for this case.
Date
Submit
