Medical History Form – Crystal Dental, Fergus ON, Canada

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1Basic Information

2Questionnaire

3Office Policy and Consent

Contact Information

Name *

First

Last

Date of Birth *

Address ( Home )

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone (Home)

Address (Business)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone (Business)

Occupation

Who referred you to our office ?

In case of Emergency, We should notify:

Name *

First

Last

Relationship

Day-Time Phone

Name of Family Doctor / Medical Specialist

Phone or Address of Doctor / Medical Specialist

Signature

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.

1. Are you currently being treated for any medical condition or have you been treated within the past year? *

Yes
No
Not Sure/Maybe

Response – Are you currently being treated for any medical condition or have you been treated within the past year?

If Yes, Please Explain

2. When was your last medical checkup ?

3. Has there been any change in your general health in the past year ?

Yes
No
Not Sure/Maybe

Response – Has there been any change in your general health in the past year ?

If Yes, Please Explain

4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind ?

Yes
No
Not Sure/Maybe

Response – Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

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

Yes
No
Not Sure/Maybe

a) Medications

b) Latex / Rubber Products

c) Other (e.g. Hay fever, Seasonal / Environmental, Foods)

6. Have you ever had a peculiar or adverse reaction to any medicines or injections?

Yes
No
Not Sure/Maybe

Response – Have you ever had a peculiar or adverse reaction to any medicines or injections?

If Yes, Please explain

7. Do you have or have you ever had asthma ?

Yes
No
Not Sure/Maybe

8. Do you have or have you ever had any heart or blood pressure problems ?

Yes
No
Not Sure/Maybe

9. 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

10. Do you have a prosthetic or artificial joint ?

Yes
No
Not Sure/Maybe

11. 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

12. Have you ever had hepatitis, jaundice or liver disease ?

Yes
No
Not Sure/Maybe

13. Do you have a bleeding problem or bleeding disorder ?

Yes
No
Not Sure/Maybe

14. Have you ever been hospitalized for any illnesses or operations ?

Yes
No
Not Sure/Maybe

Response – Have you ever been hospitalized for any illnesses or operations

If Yes, Please explain

15. 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)

16. Are there any conditions or diseases not listed above that you have or have had ?

Yes
No
Not Sure/Maybe

Response – Are there any conditions or diseases not listed above that you have or have had

If yes, please explain

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

Yes
No
Not Sure/Maybe

18. Do you smoke or chew tobacco products ?

Yes
No
Not Sure/Maybe

19. Are you nervous during dental treatment ?

Yes
No
Not Sure/Maybe

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

Yes
No
Not Sure/Maybe

Delivery Date

21. Do you identify as a patient with a disability?

Yes
No
Not Sure/Maybe

Response – Do you identify as a patient with a disability?

If yes, please explain.

We are committed to support you in understanding your dental health, so that you will always be able to make the best choices.

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another healthcare provider may be necessary, and I consent to the release of this information.

I authorize release to my insuring company plan administrator, the information contained in claims submitted electronically and when applicable hereby assign my benefits to Drs. James Chacko, Hamsaveni James and/or associates and authorize payment directly to Crystal Dental. Further, I agree that I am fully responsible for the total payment of all procedures performed in this office. This includes any treatment that is not a benefit of any dental insurance that I may have.

MISSED APPOINTMENTSAppointment Times are reserved especially for you. Please be on time so that the scheduled treatment can take place.

If for any reason you should need to change your appointment, there will be no charge, provided you give us 2 full business days notice. If an appointment is cancelled with less than 48 hours notice, a potential fee of $50 may be applied to your account.

Please help us serve you better by keeping your scheduled appointments. We are here to assist you in any way possible. If you have any questions or concerns, please advise our team.

Our goal is to ensure that you have an outstanding experience here at Crystal Dental!

Name *

First

Last

Email *

Signature (Responsible Party) Witness *

Date