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141 Sheppard Ave W
Toronto M2N 1M7
Ontario
Canada
Tel 416-485-0321
Fax 416-485-0327
Email Us

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)

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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