Medical History Questionnaire


    Mr.MissMrs.Ms.Dr.


    In Case of Emergency, We Should Notify:


    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.


    YesNoNot Sure/Maybe


    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe



    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe
    chest pain, anginaheart attackstroke, TIAheart murmurrheumatic fever
    mitral valve prolapsetuberculosiscancerpacemakerlung disease
    stomach ulcersarthritissteroid therapydiabetesthyroid disease
    drug/alcohol/cannabis use or dependencyseizures (epilepsy)kidney diseaseshortness of breathosteoporosis medications (e.g. Fosamax, Actonel)

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe

    YesNoNot Sure/Maybe


    YesNo






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


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