Medical History Form

Family Dentistry Serving Courtice, Oshawa and Durham Region

 5-1414 King St. E

905-434-5500

Thank you for choosing King Town Dental

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2Please review selections carefully before progressing to the next section.

Medical Alert

Sex *

Male
Female
Prefer Not to Say

Name *

First

Middle

Last

Date of Birth *

Address (Home)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Occupation *

How did you hear about to our office? *

In case of emergency, we should notify:

Name *

Relationship *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Day-Time Phone *

Name of Family Doctor *

Phone

Address

Address Line 1

City

State / Province / Region

Postal Code

Do you have any medical specialists?

(1) Name of Medical Specialist

Area of Specialty

Phone

Address

Address Line 1

City

State / Province / Region

Postal Code

(2) Name of Medical Specialist

Area of Specialty

Phone

Address

Address Line 1

City

State / Province / Region

Postal Code

Physician Information

Name of Physician *

Phone Number

Address

Address Line 1

City

State / Province / Region

Postal Code

Medical History

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 out the entire form.

Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain. *

Yes
No
Unsure / Maybe

Please explain. *

When was your last medical checkup?

Has there been any change in your general health in the past year? If yes, please explain. *

Yes
No
Unsure / Maybe

Please explain. *

Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list them. *

Yes
No
Unsure / Maybe

Please list them. *

Do you have any allergies? *

Yes
No
Unsure / Maybe

Please list them using the categories below. *

Medications
Latex / Rubber Products
Other (Hay fever, seasonal/environmental, foods...)

Please Elaborate (Medications) *

Please Elaborate (Latex / Rubber Products) *

Please Elaborate (Other) *

Have you ever had a perculiar or adverse reaction to any medicines or injections? If yes, please explain. *

Yes
No
Unsure / Maybe

Please explain. *

Do you have or have you ever had asthma? *

Yes
No
Unsure / Maybe

Do you have or have you ever had any heart or blood pressure problems? *

Yes
No
Unsure / Maybe

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? *

Yes
No
Unsure / Maybe

Do you have a prosthetic or artificial joint? *

Yes
No
Unsure / Maybe

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)? *

Yes
No
Unsure / Maybe

Have you ever had hepatitis, jaundice or liver disease? *

Yes
No
Unsure / Maybe

Do you have a bleeding problem or bleeding disorder? *

Yes
No
Unsure / Maybe

Have you ever been hospitalized for any illnesses or operations? If yes, please explain. *

Yes
No
Unsure / Maybe

Please explain. *

Do you have or have you had any of the following?

Chest pain, angina
Rheumatic fever
Pacemaker
Steroid therapy
Seizures (epilepsy)
Heart attack
Mitral valve prolapse
Lung disease
Diabetes
Kidney disease
Stroke, TIA
Tuberculosis
Stomach ulcers
Thyroid disease
Shortness of breath
Heart murmur
Cancer
Arthritis
Drug/alcohol/cannabis use or dependancy
Osteoporosis medications (e.g. Fosamax, Actonel)

Elaborate if necessary.

Are there any conditions or diseases not listed above that you have or have had? If yes, please explain. *

Yes
No
Unsure / Maybe

Please explain. *

Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)? *

Yes
No
Unsure / Maybe

Do you smoke or chew tobacco products? *

Yes
No
Unsure / Maybe

Are you nervous during dental treatment? *

Yes
No
Unsure / Maybe

Are you breastfeeding or pregnant? *

Breastfeeding
Pregnant
No
Unsure / Maybe

Expected delivery date? *

Do you identify as a patient with a disability? If yes, please explain. *

Yes
No
Unsure / Maybe

Please explain. *

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

Patient/Parent/Guardian Signature: *

Clear Signature

Date *

Dentist Signature:

Clear Signature

Date

Dentist's Notes:

King Town Dental

Dr. Sabrina Bedi, DDS

Courtice Dentist
5-1414 King St. E  (external map)
Townline Centre

905-434-5500

Opening Hours

Same Day Emergencies Accommodated

Monday | 9am - 6pm
Tuesday | 9am - 6pm
Wednesday | 10am - 7pm
Thursday | 10am - 7pm

Referring Offices
Patient Information
Dental Treatments
Canadian Dental Care Plan
Contact Us
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