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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