Medical History Questionnaire

Please complete the form below; for best results use Google Chrome or Mozilla Firefox browsers.

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

NAME: *

DATE OF BIRTH (DAY/MONTH/YEAR):

ADDRESS (HOME): *

Please include city and post code.

Phone Numbers: *

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

ADDRESS (BUSINESS):

OCCUPATION:

WHO REFERRED YOU TO OUR OFFICE?

IN CASE OF EMERGENCY, WE SHOULD NOTIFY: *

(Name + Relationship)

EMERGENCY CONTACT PHONE NUMBER: *

NAME OF FAMILY DOCTOR: *

PHONE NUMBER OF FAMILY DOCTOR: *

ADDRESS OF FAMILY DOCTOR:

(1) NAME OF MEDICAL SPECIALIST:

AREA OF SPECIALITY: PHONE AND/ OR ADDRESS:

(2) NAME OF MEDICAL SPECIALIST:

AREA OF SPECIALITY: PHONE AND/ OR ADDRESS:

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.

Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain?

Yes
No
Not Sure / Maybe

If yes, please explain.

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.

Do you have a prosthetic or artificial joint?

Yes
No
Not Sure / Maybe

If yes, where

Have you ever had hepatitis, jaundice or liver disease?

Yes
No
Not Sure / Maybe

If yes, how long ago?

Have you ever been hospitalized for any illnesses or operations?

Yes
No
Not Sure / Maybe

If yes, for what

Do you smoke, vape or chew tobacco products? How often?

Smoke
Vape
Chew tobacco
Consume marijuana

If yes, how often?

When was your last medical checkup?

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 and explain your reaction.

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

If yes, please list them.

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

If yes, what kind of condition

Do you have a bleeding problem or bleeding disorder?

Yes
No
Not Sure / Maybe

If yes, what kind of disorder

Do you identify as a patient with a disability?

Yes
No
Not Sure / Maybe

If yes, please explain.

Do you like the appearance of your teeth?

Yes
No
Not Sure / Maybe

If no, what are your concerns?

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

Are you nervous during dental treatment?

Yes
No
Not Sure / Maybe

Are there any conditions or diseases not listed above that you have or have had? If yes, please explain.

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

If yes, please list.

Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?

Yes
No
Not Sure / Maybe

If yes, what date?

To the best of my knowledge, the above information is correct:

Dentist Signature / Notes & Date

Patient/Parent/Guardian Signature:

Date / Time

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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

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