Medical History Form

• MR

• MISS

• MRS

• MS

• DR

NAME:^*

DATE OF BIRTH (DAY-MONTH-YEAR):

ADDRESS (HOME):

HOME PHONE:

EMAIL ADD:

OCCUPATION:

WHO MAY WE THANK FOR THE REFERRAL?:

IN CASE OF EMERGENCY, WHOM SHOULD WE NOTIFY?

NAME:

RELATIONSHIP:

DAYTIME PHONE:

NAME OF FAMILY DOCTOR:

PHONE OR ADDRESS:

NAME OF MEDICAL SPECIALIST (ex: Cardiologist):

1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why?

2. When was your last medical check up?

3. Has there been any change in your general health in the past year? If yes, please explain.

4. Are you taking any medications, non-prescription drugs or herbal supplement of any kind? If yes, please list.

5. Do you have any allergies/sensitivities? If you answered yes, please list using the categories below:

a) Medications

b) Latex/rubber products

c) Other (e.g. hay fever, foods)

6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.

7. Do you have or have you ever had asthma?

8. Do you have or have you ever had any heart or blood pressure problems?

9. Are you required to take antibiotics prior to dental/medical procedures, due to heart/valve problems and/or hip/joint replacement?

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

11. Have you ever had hepatitis, jaundice or liver disease?

12. Do you have a bleeding problem or a bleeding disorder?

13. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.

14. Do you have or have you ever had any of the following? Please check.

• Chest pain

• Rheumatic fever

• Pacemaker

• Steroid therapy

• Heart attack

• Mitral valve prolapse

• Lung disease

• Diabetes

• Stroke

• Heart murmur

• Tuberculosis

• Stomach ulcers

• Shortness of breath

• Angina

• Cancer

• Arthritis

• Prosthetics cardiac valve/repair

• History of infective endocarditis

• Depression

• Cardiac transplant

• Seizures (Epilepsy)

• Kidney disease

• Thyroid disease

• Parkinson's

• Osteoporosis medications (e.g. Fosamax, Actonel)

• Drug and Alcohol dependency

15. Are there any conditions or diseases not listed above that you have or have had? If so, what

16. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)

17. Do you smoke or chew tobacco products?

18. Do you use cannabis?

19. Are you nervous during dental treatment?

20. For women only: Are you breastfeeding or pregnant, what is the expected delivery date?

I Consent and understand that in some cases Dr. Malette/Morin may need to contact my medical doctor for additional information.
To the best of my knowledge, the above information is correct:

PATIENT/PARENT/GUARDIAN SIGNATURE:

DATE: