Health History Form

For patients

You can fill out the form below and submit it to Bay Bloor Endodontics electronically, or you can download the document, fill it out, and bring it with you when you visit us.

Health History Form (pdf)

Patient Information
  1. Title
  2. (required)
  3. (required)
Address
  1. (required)
  2. (required)
  3. (required)
Telephones
Dental Insurance
  1. Do you have dental insurance?
Referral
  1. (required)
  2. (required)
  3. (required)
Medical History
  1. Are you in good health?
  2. Have you seen a physician within two years for active treatment or checkup?
  3. Are you taking any medications?
  4. Are you sensitive or allergic to any other medication?
  5. Have you ever had an unfavorable reaction following dental treatment?
  6. Have you ever had excessivebleeding requiring special treatment?
  7. Do you suffer from Jaw Joint ( TMJ) Problems?
  8. Female Patients: Are you pregnant?