Medical History Bringing your best smile to life Contact Us Patient Dental History FormMedical History FormInsurance Information FormOffice Policy Form Medical History EmailThis field is for validation purposes and should be left unchanged.Legal name(Required)Email(Required) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone numberCell PhoneAlternate phone numberPhysicianDate of last medical examination?Have you ever been hospitalized? YES NO If yes, please provide details with datesDo you have any heart, or circulatory problems(including stroke)? YES NO Please describeDo you have a pacemaker? YES NO Have you ever been advised to take antibiotic pre-medication prior to dental treatment? YES NO Do you have allergies to medications? Food? Seasonal hay fever? Other? Please ListMedications and purpose for takingMedication #1Reason for medication #1Medication #2Reason for medication #2Medication #3Reason for medication #3Medication #4Reason for medication #4Medication #5Reason for medication #5Medical HistoryHave you ever had a reaction to any kind of medicine or dental anesthetic? YES NO If yes, please provide detailsAre you pregnant, or think you may be pregnant? YES NO Breastfeeding? YES NO Please indicate below (√) if you presently have or have ever had any of the following: AIDS/HIV Alcohol or chemical dependency Rheumatoid Arthritis/Osteoarthritis Artificial joints or valves Asthma Blood transfusion Cancer/radiotherapy/chemotherapy High Cholesterol or taking statin drugs Head or neck injury Breathing or sleeping problems Diabetes Eating Disorders Osteoporosis Fainting/dizzy spells High blood pressure Low blood pressure Hyper/hypo glycemia Kidney disease Prolonged bleeding Digestive disorders/reflux Epilepsy/seizures Liver disease (Hepatitis/Jaundice) Lung Disease/chest pains Mental Illness ADHD Autism Spectrum Disorder Tuberculosis Viral infections/cold sores Thyroid disorder Glaucoma STI/STD Do you smoke or vape? YES NO if yes, which one?if yes, how much per day?if yes, how much per week?Do you ingest or smoke cannabis(cannabinoids)? YES NO if yes, which one?if yes, how much per day?if yes, how much per week?Do you drink alcohol? YES NO if yes, how much per day?if yes, how much per week?Please list any additional medical information including any treatment you may be undergoing?Patient/Parent/Guardian Signature(Required) Δ Patient Dental History FormMedical History FormInsurance Information FormOffice Policy Form
(250) 721-2221
(250) 721-2221