New Patient Health History

1 Patient information

First name *

Last name *

Date of birth *

Occupation

Home address

Phone *

Email

Emergency contact

Emergency contact phone

Family physician

Physician phone

2 Dental insurance

Do you have dental insurance?

Insurance provider

Plan holder (if not you)

Please bring your insurance card to your first visit — no policy numbers needed here.

3 Medical history

Please answer as accurately as you can. If you're unsure, we'll go over it together at your visit.

1.Are you currently being treated for any medical condition, or have you been treated within the past year?

YesNo

2.When was your last medical checkup?

3.Has there been any change in your general health in the past year?

YesNo

4.Are you taking any medications, non-prescription drugs, or herbal supplements of any kind?

YesNo

5.Do you have any allergies? (medications, latex/rubber products, or other — e.g. foods, seasonal)

YesNo

6.Have you ever had a peculiar or adverse reaction to any medicines or injections?

YesNo

7.Do you have or have you ever had asthma?

YesNo

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

YesNo

9.Have you ever had a replacement or repair of a heart valve, an infection of the heart (infective endocarditis), a heart condition from birth (congenital heart disease), or a heart transplant?

YesNo

10.Do you have a prosthetic or artificial joint?

YesNo

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

YesNo

12.Have you ever had hepatitis, jaundice, or liver disease?

YesNo

13.Do you have a bleeding problem or bleeding disorder?

YesNo

14.Have you ever been hospitalized for any illnesses or operations?

YesNo

4 Do you have, or have you ever had, any of the following?

Please check all that apply.

5 A few more questions

16.Are there any conditions or diseases not listed above that you have or have had?

YesNo

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

YesNo

18.Do you smoke or chew tobacco products?

YesNo

19.Are you nervous during dental treatment?

YesNo

20.Are you breastfeeding or pregnant?

YesNo

21.Do you identify as a patient with a disability?

YesNo

6 Consent & acknowledgement

Signature (type your full name) *

Date *

For patients under 18, a parent or legal guardian should complete and sign this form.

1 Patient information

2 Dental insurance

3 Medical history

4 Do you have, or have you ever had, any of the following?

5 A few more questions

6 Consent & acknowledgement

Thank you — your health history is complete