Medical History Questionnaire

Oxford Family Dental

Book Appointment

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Call The Office

+1 (604) 942-1006

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Office Location

#3120-1971 Lougheed Hwy
Port Coquitlam, B.C., V3B 0K2

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Email Us

info@oxfordfamilydental.com

MEDICAL HISTORY QUESTIONNAIRE

PATIENT DETAILS

Patient Name *

First

Last

Date of Birth *

Sex *

Email *

Cell Phone Number *

Home Phone Number

Work Phone

Can We Leave a Message?

Home
Cell
Work

Please tick all that apply

Mailing Address *

Address Line 1

City

State / Province / Region

Postal Code

When was your last dental visit? *

Do you have Dental Insurance? *

Insurance Carrier Name

Policy Holder Name

Policy Holder Date of Birth

Plan, Policy or Group #

ID or Certificate #

Occupation

Employer Name *

Employer Phone Number

Secondary Insurance? If so, Name of ins holder / carrier / plan / id #

Reason For Appointment *

EMERGENCY CONTACT INFORMATION

Emergency Contact Email *

Emergency Contact's Name *

First

Last

Relationship *

Emergency Contact Phone Number *

Name of Family Doctor

BACKGROUND INFORMATION

Are you being treated for any medical condition at the present time or have you been treated within the past year? If so, why? *

If Yes, please explain.

When was your last medical checkup?

Has there been any change in your general health in the past year. If yes, please explain. *

If Yes, please explain.

Have you had any surgeries in the past five years? If yes, please explain. *

If Yes, please explain.

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

If Yes, please explain.

Do you have any allergies? If you answered yes, please list using the categories below

No
Medication & Antibiotics
Latex Products
Other

If Yes, please explain.

Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain. *

If Yes, please explain.

Do you have or have you ever had asthma? *

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

If Yes, please explain.

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? *

If Yes, please explain.

Do you have a prosthetic or artificial joint? *

If Yes, please explain.

Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV Infection, radiotherapy, chemotherapy? *

If Yes, please explain.

Have you ever had hepatitis (A,B,C or another form) jaundice or liver disease? *

If Yes, please explain.

Do you have a bleeding problem or bleeding disorder? *

If Yes, please explain.

Have you ever been hospitalized for any illness or operations? If yes please explain. *

If Yes, please explain.

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

If Yes, please explain.

Are there any diseases or medical problems that run in your family? *

If Yes, please explain.

Do you smoke, chew or use tobacco products? If so, Please Specify. *

If Yes, please explain.

Are you nervous during dental treatment? *

Are you breastfeeding or pregnant? *

FINAL STEPS

Additional Questions or Comments

CONTACT US



Call The Office

+1 (604) 942-1006



Office Location

#3120-1971 Lougheed Hwy
Port Coquitlam, B.C., V3B 0K2



Email Us

info@oxfordfamilydental.com

Oxford Family Dental

Oxford Family Dental

+1 (604) 942-1006

Info@oxfordfamilydental.com