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141 Sheppard Ave W
Toronto M2N 1M7
ON CA
Tel 416-485-0321
Fax 416-485-0327

Medical Dental History

Instructions:
To receive treatment in this office you must answer all questions on this history form. The
questions asked relate directly to the safe and effective treatment you are to receive in this office
– to the best of your ability honest answers must be given. If you are unsure of the questions,
unsure of your answer, or whether the question relates to your medical condition, you are to
discuss the matter with the doctor. Some of the questions may not relate to your medical
condition; in that event you are to write “N/A” (not applicable) in the space provided. All
questioned must be answered. To properly evaluate your current health status it may be
necessary for the dentist to contact other health professional. Included in this form is “Permission
To Obtain and Release Information”.
All information you supply on this form, and subsequent information from the interview by the
dentist and anything received from your physician or any other source, will be held in the strictest
confidence, and will not be disclosed without your permission.

 

User Information

Name:    Email Address :

Date

Date :

Telephone Number

Family Physician :
Medical specialist :
General dentist :
Dental specialists :

Do you have any allergies?

Yes
No

Do you have any problems with freezing?

Yes
No

Are you taking any medications? (please list)

Please list :

Have you ever had or been treated for the following?

Rheumatic fever
Rheumatic heart disease
Heart murmur
Congenital heart disease

Have you ever had or been treated for the following?

Heart attack
Angina
Heart surgery
A pacemaker
Irregular heart beats

Have you ever had or been treated for the following?

AIDS
HIV-positive

Have you ever had or been treated for the following?

Stomach disease
Liver disease
Hepatitis disease
Intestinal disease

Have you ever had or been treated for the following?

Abnormal blood pressure
Excessive bleeding and anemia

Have you ever had or been treated for the following?

Asthma
Breathing problems
TB
Shortness of breath
Hay fever

Have you ever had or been treated for the following?

Cancer
Xray
Treatments
Chemotherapy
Diabetes

Have you ever had or been treated for the following?

Kidney problems
Dialysis
A stroke
Convulsions
Fainting spells

Have you ever had or been treated for the following?

Turmors
Growths
Arthritis
Prosthetic valves
Joints replacement

Do you smoke?

Yes
No

Have you had any operations?

Yes
No

Have you had any Injuries?

to head?
to neck?

Counselling or treatment by psychologist or psychiatrist?

Yes
No

Special diet?

Yes
No

Have you been advised to take an antibiotic before dental treatment?

Yes
No

Have you ever fainted during a dental appointment?

Yes
No

Have you ever had an allergic reaction?

Yes
No

Had a bleeding problem?

Yes
No

Do you grind or clench your teeth?

Yes
No

Are your teeth sensitive to hot and cold?

Yes
No

Do you have clicking or pain in the jaw joint around your ear?

Yes
No

Do you get frequent headaches?

Yes
No

Do get anxious before a dental appointment?

Yes
No
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