Medical History Questionnaire

The following information is required to enable us to provide you with the best possible dental care. All information is strictly confidential and protected by doctor–patient confidentiality. Please complete the entire form.

Patient Information










Emergency Contact





Family Doctor



How Did You Hear About Us?








Medical History

Please select the best answer for each question.

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





2. When was your last medical checkup?

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





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





5. Do you have any allergies?







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





7. Do you or have you ever had Asthma?




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




9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (infective endocarditis), a heart condition from birth, or a heart transplant?




10. Do you have a prosthetic or artificial joint?




11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?




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




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




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




15. Do you have any of the following? (Check all that apply)





















16. Is there any disease or medical problem not listed that you may have or have had?




17. Are there any diseases or medical problems that run in your family? (Cancer, Diabetes, etc.)



18. Do you smoke or chew tobacco products?




19. Are you nervous during dental treatment?




20. Are you breastfeeding or pregnant? If yes, how far along?




21. Do you identify as a person with a disability? Please explain.




22. When was your last dental visit?

To the best of my knowledge, the above information is correct.