Medical & Dental History Form

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

Medical & Dental History

First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
Phone*
Email
Address (Home)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation
Name of family doctor
Phone or address of family doctor
Name of medical specialist
Area of specialty
Phone or address of medical specialist
Who referred you to our office?
Emergency Contact
In case of emergency, we should notify:
Name*
First Last
Relationship*
Day-time Phone*
Medical History
Are you currently being treated for any medical condition or have you been treated within the past year?*
- Yes
- No
- Not sure / maybe
If yes, please explain:
When was your last medical checkup?
Has there been any change in your general health in the past year?*
- Yes
- No
- Not sure / maybe
If yes, please explain:
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*
- Yes
- No
- Not sure / maybe
If yes, please list them:
Do you have any allergies?*
- Yes
- No
- Not sure / maybe
If yes, please list them:
Have you ever had a peculiar or adverse reaction to any medicines or injections?*
- Yes
- No
- Not sure / maybe
If yes, please explain:
Do you have or have you ever had asthma?*
- Yes
- No
- Not sure / maybe
Do you have or have you ever had any heart or blood pressure problems?*
- Yes
- No
- Not sure / maybe
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?*
- Yes
- No
- Not sure / maybe
Do you have a prosthetic or artificial joint?*
- Yes
- No
- Not sure / maybe
Do you have any conditions or therapies that could affect your immune system (e .g . leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*
- Yes
- No
- Not sure / maybe
Have you ever had hepatitis, jaundice or liver disease?*
- Yes
- No
- Not sure / maybe
Do you have a bleeding problem or bleeding disorder?*
- Yes
- No
- Not sure / maybe
Have you ever been hospitalized for any illnesses or operations?*
- Yes
- No
- Not sure / maybe
If yes, please explain:
Do you have or have you ever had any of the following? Please check.
- chest pain, angina
- heart attack
- stroke, TIA
- heart murmur
- rheumatic fever
- mitral valve prolapse
- tuberculosis
- cancer
- pacemaker
- lung disease
- stomach ulcers
- arthritis
- steroid therapy
- diabetes
- thyroid disease
- drug/alcohol/cannabis use or dependency
- seizures (epilepsy)
- kidney disease
- shortness of breath
- osteoporosis medications (e .g . Fosamax, Actonel)
Are there any conditions or diseases not listed above that you have or have had?*
- Yes
- No
- Not sure / maybe
If yes, please explain:
Are there any diseases or medical problems that run in your family (e .g . diabetes, cancer or heart disease)?*
- Yes
- No
- Not sure / maybe
Do you smoke or chew tobacco products?*
- Yes
- No
- Not sure / maybe
Are you breastfeeding or pregnant?*
- Yes
- No
- Not sure / maybe
If pregnant, what is the expected delivery date?
Do you identify as a patient with a disability?*
- Yes
- No
- Not sure / maybe
If yes, please explain:
Dental History
What is the reason for your visit today? Are you currently experiencing any dental problems?*
Have you been seeing a dentist regularly?*
- Yes
- No
- Not sure / maybe
If not, please explain:
Are you nervous during dental visits?*
- Yes
- No
- Not sure / maybe
Have you had a bad experience or complications during dental treatment?*
- Yes
- No
- Not sure / maybe
If yes, please explain:
When was your last dental visit? What was done at that appointment?
When did you last have dental x-rays?
Have you ever seen a dental specialist?*
- Yes
- No
- Not sure / maybe
How often do you brush your teeth?*
How often do you floss your teeth?*
Do your gums bleed when you brush or floss?*
- Yes
- No
- Not sure / maybe
Have you been told to take antibiotics before a dental appointment?*
- Yes
- No
- Not sure / maybe
Do you feel that you have bad breath?*
- Yes
- No
- Not sure / maybe
Do you have any problems with your jaw (clicking, limited movement, pain)?*
- Yes
- No
- Not sure / maybe
Do you clench or grind your teeth during the day?*
- Yes
- No
- Not sure / maybe
Do you have any problems with your sleep (restlessness, grinding, sleep apnea) or wake up with headaches?*
- Yes
- No
- Not sure / maybe
Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?*
- Yes
- No
- Not sure / maybe
If yes, please explain:
If yes, please explain:
Is there anything about the appearance of your teeth or smile that you would like to change?*
- Yes
- No
- Not sure / maybe
If yes, please explain:
Do you have dental insurance?
- Yes
- No
Primary Insurance Company
Group Policy Number
Certificate Number
Secondary Insurance Company
Group Policy Number
Certificate Number
Certification of accuracy of information:*
To the best of my knowledge, the above information is correct.
Personal Information Consent*
All staff members at the Stirling Dental Centre understand the importance of protecting your personal information. We are committed to collecting, using and disclosing this information in a responsible manner according to the standards of the Royal College of Dental Surgeons of Ontario and the law. We collect this information in order to:

- Contact and communicate with you regarding your health care, update your patient information, schedule and confirm appointments
- Review your medical history to diagnose dental conditions, advise you of your treatment options, and provide safe care
- Communicate with other health-care providers involved in your treatment including your family doctor, pharmacist, specialists and referring doctors regarding your health care
- Follow-up on treatment, care, and billing
- To process credit card payments or collect unpaid accounts
- Complete and submit claims for payment or reimbursement from third party benefit providers, insurance companies and government agencies
- For teaching and demonstrating purposes on an anonymous basis
- To comply with legal and regulatory requirements, including delivery of patient charts and records to governing bodies in a timely fashion, when required, according to the Regulated Health Professions Act
- To permit potential purchasers, practice brokers or advisors to evaluate the practice
- To prepare materials for the Health Professions Appeal and Review Board

We also collect, use and disclose personal information when permitted or required by law, under the terms of the Regulated Health Professions Act. The storage, retention, and destruction of your personal information complies with existing legislation, and privacy protocols.
I have reviewed the above information and give my informed consent for the collection, use and/or disclosure of my personal information for the purposes that are listed.

Medical & Dental History Form

Medical & Dental History

Emergency Contact

Medical History

Dental History