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About Us
Services
Locations
- London Ontario Office
- Sarnia Ontario Office

For The Dreamer
For The Parents
Forms

Adults: Medical History Form

For parent/Guardian or Patient

Adults: Medical History Form

Free Text

For the following questions, select yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

Current Date:

Full Name:

Email Address:

Phone:

Weight:

Height:

Date of Birth:

1. Are you in good health?

Yes

No

2. Has there been any change in your general health within the past year?

Yes

No

Date of my last physical examination?

3. Are you now under the care of a physician?

Yes

No

If so, what is the condition being treated?

The name and address of my physician(s) is (are):

5. Have you had any serious illness, operation, or been hospitalized in the past 5 years?

Yes

No

6. Are you taking any medicine(s) including non-prescription medicine?

Yes

No

If so, what medicine(s) are you taking?

7. Do you have or have you had any of the following diseases or problems? Please select all that apply.

- Damaged heart valves or artificial heart valves, including heart murmur or rheumatic heart disease?

- Cardiovascular disease (heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke)

- Do you have chest pain upon exertion?

- Are you ever short of breath after mild exercise or when lying down?

- Do your ankles swell?

- Do you have inborn heart defects?

- Do you have a pacemaker?

- Allergy (foods, medications, latex, other)

- Sinus trouble

- Asthma or hay fever

- Fainting spells or seizures

- Persistent diarrhea or recent weight loss

- Diabetes

- Hepatitis

- AIDS or HIV infection

- Thyroid problems

- Respiratory problems, emphysema, bronchitis, etc

- Arthritis or painful swollen joints

- Stomach ulcer or hyperacidity

- Kidney trouble

- Tuberculosis

- Persistent cough or cough that produces blood

- Persistent swollen glands in neck

- Low blood pressure

- Sexually transmitted disease

- Epilepsy or other neurological disease

- Problems with mental health

- Problems of the immune system

- Have you or anyone in your family been diagnosed with Malignant Hyperthermia?

- Have any tests been done to secure a diagnosis of Malignant Hyperthermia?

8. Have you had abnormal bleeding?

Yes

No

9. Do you have any blood disorder such as anemia?

Yes

No

10. Have you ever had any treatment for a tumour or growth?

Yes

No

11. Do you suffer from sleep apnea?

Yes

No

12. Have you every been diagnosed with sleep apnea or any sleep disorder?

Yes

No

Do you use a CPAP or any other device to help with breathing while sleeping?

Yes

No

14. Do you smoke?

Yes

No

If so, how many years have you smoked?

15. Do you drink alcohol?

Yes

No

List the amount and frequency of drinks.

16. Do you use recreational drugs?

No

Yes

If yes, allow a few lines to list what recreational drugs. "Please note that any recreational drugs need to be listed, such as cocaine, marijuana, heroin, etc."

17. Are you allergic to or have you ever had a reaction to:

- Local Anesthetic

- Penicillin or other antibiotics

- Sulfa drugs

- Barbituates, sedatives, or sleeping pills

- Aspirin

- Iodine

- Codeine or other narcotics

- Other

List of other medicines with allergic reaction:

18 .Have you had any serious trouble associated with any previous dental treatment?

Yes

No

If so, please explain

18. Have you or your family ever had any problems with anesthesia for any procedures or operations?

Yes

No

If so, please explain

19 .Do you have any diseases, condition or problem not listed above that you think I should know about?

Yes

No

20. Are you wearing contact lenses?

Yes

No

21. Are you wearing removable dental appliances?

Yes

No

List any and all operations and procedures you've had that involved anesthesia or sedation:

List all medications (including homeopathic medicaments) you are currently using:

22. Are you pregnant or is there any chance you could be pregnant?22.

Yes

No

23. Do you have any problems associated with your menstrual period?

Yes

No

24. Are you nursing?

Yes

No

25. Are you taking birth control pills?

Yes

No

Please list any dental concerns you would like investigated:

I certify that I have read and understand the above. I acknowledge that my questions, if any about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, anesthesiologist, or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

Please check the box if you agree.

Thank you for contacting us.
We will get back to you as soon as possible.

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Dentistry While You Dream is dedicated to the health, safety and comfort of all of our Dreamers.

Our team is highly qualified and trained to help you obtain a healthy mouth and beautiful smile.

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