Dr. Johnson Dental History Questionnaire

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Dr. Dexter Johnson M.D D.D.S F.R.C.D (C) Dip ABOMS

In order to provide safe dental care for our patients, we are asking you to fill out the following questionnaire. Please answer the questions as accurately as you can. If you have any questions or doubts, check the not sure / maybe choice. Your responses will be reviewed with you by the dentist. You can be assured that the information you provide will be kept in the strictest confidence.

NAME: MR./MISS/MRS./MS./DR. *

Telephone Numbers: *

Please provide all numbers that are available - Home, Work, Cell. As well as Spouse Cell + Work.

Occupation:

Marital Status:

M S W D

In Case Of Emergency Notify: *

(Name + Relationship)

Emergency Contact Phone Number: *

Are You Covered By Any Type Of Dental Insurance?

Insurance (Group / Policy):

Policy Holder Date Of Birth:

ADDRESS (HOME): *

Please include city and post code.

Date Of Birth (DAY/MONTH/YEAR):

Place Of Business: *

Name Of Spouse:

Relationship:

Name Of Family Doctor:

Name Of Insurance:

Policy Holder:

Referred By Dentist:

Do you have any allergies? (Food Or Drugs)

Yes
No
Not Sure / Maybe

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.

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

Yes
No
Not Sure / Maybe

If yes, please explain.

Have you ever had a rheumatic fever?

Yes
No
Not Sure / Maybe

Have you ever been told you should not give blood?

Yes
No
Not Sure / Maybe

Do you have a tendency to bruise easily or bleed for prolonged period of time?

Yes
No
Not Sure / Maybe

Have you ever taken or are you currently on a oral IV bisphosphonate?

Yes
No
Not Sure / Maybe

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

Yes
No
Not Sure / Maybe

When was your last visit to a physician?

Are you taking any medications, non-prescription drugs of any kind?

Yes
No
Not Sure / Maybe

If yes, please list them.

Do you have a heart or blood pressure problems?

Yes
No
Not Sure / Maybe

Do you have a heart murmur or mitral valve prolapse?

Yes
No
Not Sure / Maybe

Have you ever had hepatitis, jaundice or liver disease?

Yes
No
Not Sure / Maybe

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

Yes
No
Not Sure / Maybe

Have you ever been hospitalized for any serious illnesses or operations?

Yes
No
Not Sure / Maybe

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)
none of the above

If yes, please explain.

Do you smoke or chew tobacco?

Women: Are you pregnant?

Yes
No
Not Sure / Maybe

Dental History

When was your last dental visit?

When did you have your last dental X-ray?

How often do you floss your teeth?

Do any of your teeth ache?

Yes
No
Not Sure / Maybe

Do you gums bleed when you brush your teeth?

Yes
No
Not Sure / Maybe

Do you feel that you have bad breath?

Yes
No
Not Sure / Maybe

Have you ever had any implant surgery in one or both of your jaws or jaw joint?

Yes
No
Not Sure / Maybe

Please list anything else not mentioned above regarding your dental history:

When did you have your last dental xray?

Yes
No
Not Sure / Maybe

How often do you brush your teeth?

Have you been seeing a dentist regularly?

Yes
No
Not Sure / Maybe

Have you ever been advised to take antibiotics before for dental appointments?

Yes
No
Not Sure / Maybe

Do you have any pain when you chew?

Yes
No
Not Sure / Maybe

Have you ever been in a vehicle accident or experienced any blows to your jaw?

Yes
No
Not Sure / Maybe

Are you being followed up with by a dental specialist?

Yes
No
Not Sure / Maybe

I the undersigned certify that all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information. I consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable including the use of local anaesthetic as indicated and I will assume responsibility for fees associated with these procedures.

Patient/Parent/Guardian Signature: *

Patients Over 18 Years Of Age.

Date / Time *

New To The Clinic ?

Blue Heron Dental Group is built on a strong reputation of over 30 years of service to the Ottawa community and the families who live here. Other dentists in the community refer pediatric patients to our clinic due to our experience and reputation when treating children.

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Contact Us

102-1500 Bank street Ottawa, Ontario K1H 7Z2

613-706-4101

Info@blueherondentalgroup.ca

Clinic Hours

Mon: 7:30am - 3:30pm
Tue: 7:30am - 3:30pm
Wed: 7:30am - 3:30pm
Thu: 7:30am - 7:30pm
Fri: 7:30am - 3:00pm

Sat: Closed
Sun: Closed