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Medical History Questionaire

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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

Book Your New Patient Examination

Submit this form or give us a call to schedule a new patient appointment for your child or other family member.

We are accepting New Patients. Our office is open Monday to Saturdays. Please call our office for details.

Medical History Questionaire

PATIENT DETAILS

EMERGENCY CONTACT INFORMATION

BACKGROUND INFORMATION

FINAL STEPS

Book Your New Patient Examination

Oxford Family Dental

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