Medical Questionnaire

Full Name of Patient

Parent or Legal Guardian

Home Address

City

Province

Postal Code

Daytime Phone Number

Cell Phone or Business Number

Emergency Contact Full Name

Emergency Contact Phone Number

Gender

Female Male Other/prefer to not say

Date of Birth

Name of your regular dentist

Name of your family doctor

If other, please specify

What type of insurance do you have?

Private Insurance Government Insurance No Insurance

Insurance Carrier

Insurance ID Number

Insurance Policy Number

Policy Holder's Full Name

Policy Holder's Date of Birth

Interim Federal Health

Yes No

ID Number

Canadian Dental Care Plan (CDCP)

Yes No

ID Number

Healthy Smiles Ontario (HSO)

Yes No

ID Number

Do you have secondary insurance?

Yes No

Private Insurance

Yes No

Interim Federal Health

Yes No

Canadian Dental Care Plan

Yes No

Healthy Smiles Ontario

Yes No

Insurance carrier

Insurance ID Number

Insurance Policy Number

Policy Holder's Full Name

Policy Holder's Date of Birth

Interim Federal Health ID Number

CDCP ID Number

HSO ID Number

Date of Last Dental Exam

Dental Concerns

Are you having pain or discomfort at this time?

Yes No

Do you feel nervous about having dental treatment?

Yes No

Have you ever had a bad experience in a dental office?

Yes No

Have you had a problem with freezing?

Yes No

Do you have any problems with your jaw?

Yes No

Do you have a severe gag reflex?

Yes No

If you have health conditions involving any part of your body, this may have a relationship with your dental health and could inﬂuence the type of dental care and the way we administer your sedation. You are helping us provide you with the best possible care by completing this questionnaire as carefully as possible.

Height (ft)

Inches (in)

Weight (kg)

Have you ever had sedation in a dental office?

Oral Sedation

Yes No

Nitrous Oxide (laughing gas)

Yes No

IV sedation

Yes No

Sleep Dentistry (general anaesthesia)

Yes No

If yes, were you satisfied with the sedation level?

Yes No

Do you have or does anyone in your family have a form of muscular dystrophy?

Yes No

Do you have, or have you had radiation therapy?

Yes No

Do you have, or have you had chemotherapy?

Yes No

Have you been treated by a physician in the last year?

Yes No

For what condition?

When was your last medical examination?

Have you been hospitalized or had an operation that required a general anaesthesia?

Yes No

Please explain the reason:

Have you or any member of your family had an adverse reaction to an anaesthetic?

Yes No

Please explain the reason:

Past and Current Conditions (check all that apply to you, now or in the past)

Cardiovascular

Were you ever told by your family doctor that you had a heart condition?

Yes No

Do you have high blood pressure?

Yes No

What year were you diagnosed?

What is your usual blood pressure?

Is your blood pressure under control according to your family doctor?

Yes No

Have you ever had a heart attack?

Yes No

What year was your heart attack?

Do you have chest pain with physical activity?

Yes No

Do you have congestive heart failure?

Yes No

Do you have heart palpitation?

Yes No

Were you ever told you had a heart murmur?

Yes No

Pulmonary

Have you been diagnosed with a lung disease?

Yes No

What type(s)?

COPD Emphysema

Do you have asthma?

Yes No

What triggers your asthma?

Have you ever been hospitalized for an asthma attack?

Yes No

Do you smoke cigarettes?

Yes No

How many packs a day?

How many years?

Do you suffer from sleep apnea?

Yes No

Endocrine

Do you have diabetes?

Yes No

What type do you have?

Type I Type II

Do you have problems with your Thyroid gland?

Yes No

Have you taken Steroid pills in the last year?

Yes No

Other Conditions

Rheumatic fever

Yes No

Stroke

Yes No

Excessive shortness of breath

Yes No

Tendency to faint when stressed

Yes No

Epilepsy or Convulsion

Yes No

Cancer

Yes No

Bleeding problems

Yes No

Anaemia

Yes No

Low blood sugar

Yes No

Chronic fatigue syndrome

Yes No

Fibromyalgia

Yes No

Stomach ulcer

Yes No

Frequent heartburn

Yes No

Glaucoma

Yes No

Motion sickness

Yes No

Limitation in neck movement

Yes No

Limitation in mouth opening

Yes No

Depression

Yes No

Anxiety Disorder

Yes No

Other Mental Disease

Yes No

Contagious diseases

Yes No

Hepatitis

Yes No

HIV/AIDS

Yes No

Liver problems

Yes No

Kidney problems

Yes No

Drug addiction

Yes No

Other conditions not mentioned?

Please list all prescribed medications (name of drug and amount per day. You can ask your pharmacist to fax a current list to 519-640-3658)

Please list all over-the-counter medication you are currently taking:

Please list all herbal medicine you are currently taking:

Do you take recreational drugs?

Yes No

Do you drink alcohol every day?

Yes No

Are you allergic, or have you had any unusual reaction to any of the following?

Penicillin

Yes No

Other antibiotics

Yes No

Codeine

Yes No

Narcotics

Yes No

Sulfa drugs

Yes No

Sulfites

Yes No

Local Anaesthetics

Yes No

Seasonal

Yes No

Animal

Yes No

Food

Yes No

Other substances or medications not listed:

Reaction or symptoms:

Prostheses

Do you have any artificial joints (knee or hip for example)?

Yes No

Have you ever had a heart valve replacement?

Yes No

Do you wear dentures (partial or complete)?

Yes No

Do you wear contact lenses?

Yes No

Women only: Is there a possibility you could be pregnant?

Yes No

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Medical Questionnaire

Medical Questionnaire

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