MEDICAL HISTORY QUESTIONNAIREIn order to give you the best dental care, we require the client information below. All information is strictly confidential. Some questions may seem unimportant for this visit, but may be vital in case of emergency so please answer every question. Please feel free to ask for help.1. PERSONAL HISTORYClient Name:Home Address:Date of Birth:Marital Status:

Single Married Other

Name of Partner/Spouse:

Occupation:Employer Name:

Home Phone:Work Phone:

Students:Mother’s Name:

Father’s Name:

Do you have dental insurance?

Yes No

Insurance Company:

2. MEDICAL HISTORYName of Family Doctor:1. To the best of your knowledge, are you in good health? Yes No2. Have you ever had a serious illness or are you under a doctor’s

care? Yes No3. Have you seen a doctor in the past year? Yes No4. Are you taking any medications at the present time?

If yes, please list: _____________________________________ Yes No5. Have you ever had a heart murmur? Yes No6. Do you have any allergies (especially drugs or anaesthetic)?

If yes, please list: _____________________________________ Yes No7. Do you smoke or use tobacco products? Yes No8. Have you ever had any major surgery? Yes No9. Women only: Are you pregnant? If yes, how many weeks? Yes No10.Have you ever had or been treated for any of the following? Please check each:

Strep Throat Heart Trouble Stroke Asthma Nervous Disorder Hay Fever Liver Disease Skin Rash Cancer Bruising Easily Jaundice Blood Disorder Chest Pain HIV High Blood

Pressure Epilepsy Thyroid Disease Diabetes Hives Shortness of Breath Hepatitis Face Injury Kidney Disease Jaw Injury Bleeding

Disorder Other: (please list) _________________________________________________________________

3. DENTAL HISTORY

1.What dental condition (if any) concerns you at present?

2.When was your last dental visit?

3.Have you ever had ill effects from freezing (local anaesthetic)? Yes No

I hereby consent to the dental and oral surgery procedures agreed to be necessary or advisable for myself or child, including the use of local anaesthesia and/or relative analgesia.

Signature DatePersonal information is collected under the authority of the Health Protection and Promotion Act and related legislation and in accordance with the Personal Health Information Protection Act and/or the (Municipal) Freedom of Information and Protection of Privacy Act. We collect only the personal information needed to provide public health programs and to plan and evaluate our services. Your information may be shared with others as required or permitted by law. For more information contact Northwestern Health Unit at 1-800-830-5978 or see the privacy statement on our web-site at www.nwhu.on.ca Revised: March 13,

2013