Medical Questionnaire

In order to provide safe dental care for our patients, we are asking you to fill out the following questionnaire. Please answer all the questions as accurately as you can. Your responses will be reviewed with you by the dentist and you can be assured that the information you provide will be kept in the strictest confidence.

Fields that are in BOLD are required...

Personal Information
Name:
Address:
City:
Province:
Postal Code: *No dashes or spaces
Phone Number: *Require area code with no dashes or spaces
Date of Birth:
Family Doctor:
Doctor Phone: *Require area code with no dashes or spaces
Medical Questionnaire
1 Yes No Are you being treated for any medical condition at the present or have you been treated within the last year?
2 When was your last medical checkup?
3 When was your last visit to a physician?
4 Please state your reason
5 Yes No Has there been any changes in your general health in the past year?
    If yes please list them here:
6 Yes No Are you taking any medications/Non-Prescription Drugs of any kind?
  If yes please list them here:
7 Yes No Do you have any allergies?
    If yes please list them here:
8 Yes No Have you ever had a peculiar/adverse reaction to any medications/injections?
(e.g. penicillin, aspirin, or local anesthetic"dental freezing")
    If yes please list them here:
9 Yes No Do you have heart or blood pressure problems?
10 Yes No Do you have a heart murmur or mitral valve prolapse?
11 Yes No Have you ever had rheumatic fever?
12 Yes No Do you have or have had jaundice, hepatitis or liver disease?
13 Yes No Have you been told you should not give blood?
14 Yes No Do you have any conditions that could effect your immune system (AIDS, HIV Positive, Leukemia, etc...)?
    If yes please list them here:
15 Yes No Do you have the tendency to bruise easily or bleed for a prolonged period of time after being cut?
16 Yes No Have you ever been hospitalized for any serious illness or operations?
If yes please list them here:
17 Do you have or have you had any of the following?
Please check all that apply.
Chest Pain Bronchitis Tuberculosis
Arthritis Heart Attack Emphysema
Epilepsy Diabetes Stroke
Asthma Stomach Ulcer Kidney Disease
Prosthetic Joint Drug/Alcohol Dependency
18 Yes No Are they any conditions/diseases not listed above that you have or have had?
If yes please list them here:
19 Yes No Do you smoke or chew tobacco?
20 For woman only, are you pregnant? If yes what is the expect delivery date?
Confirmation
I hereby confirm that all of the information contained in this form is correct to the best of my knowledge

©2003 Dr. Michael Melnychuk. ALL RIGHTS RESERVED
Wesite Hosted & Designed by iNet Niagara