Medical History Questionnaire

Salutation:

Dental Insurance  Yes No

Is another member of your family a patient at our office  Yes No

Any Heart Problems  Yes No
Blood Pressure  Yes No
Artificial Joints  Yes No
Rheumatic Fever  Yes No
Circulatory Problems  Yes No
Radiation Treatment  Yes No
Excessive Bleeding  Yes No
Excessive Bruising  Yes No
Ulcers (stomach)  Yes No
Sinus Trouble  Yes No
Artificial Heart Valves  Yes No
Infectious Diseases  Yes No
Allergies to Anaesthetics  Yes No
Allergies to Penicillin  Yes No
Allergies to Medications  Yes No
Allergies to Latex  Yes No
Anaemia or other Blood Disorders  Yes No
Diabetes  Yes No
Asthma  Yes No
Hepatitis  Yes No
Epilepsy  Yes No
Liver or Kidney Problems  Yes No
Tumour/Cancer History  Yes No
Hormone Replacement Therapy  Yes No
Are you currently taking any drugs or medicines?  Yes No
Does your jaw "click" or hurt?  Yes No
Do you feel you grind your teeth?  Yes No
Have you ever had orthodontic treatment?  Yes No
Do you wear a dental night guard?  Yes No
Have you ever had periodontal (gum) treatment?  Yes No
Have you ever had your bite adjusted?  Yes No
Do you bite your lips or cheeks often?  Yes No
Do you smoke?  Yes No
Do you think you have occasional bad breath?  Yes No
Do your gums ever bleed when you clean your teeth?  Yes No
Do you experience sensitivity with hot/cold?  Yes No
Do your teeth ever hurt when you bite hard?  Yes No
Does floss ever tear between your teeth?  Yes No
Does food get jammed between your teeth?  Yes No
Is there anything else you would like us to know?  Yes No

Are you pregnant?  Yes No

How long since your last dental appointment?

How often do you have dental examinations?

Previous dental x-rays were taken  Less than 1 year More than 1 year