Date:
Date of Birth:
Email:
First Name:
Last Name:
Address:
City:
Postal Code:
Home phone:
Cell phone:
Referring Dentist:
Family Dentist:
Medical History:
Do you have or have you ever had any of the following? Please check.
chest pain, angina
rheumatic fever
pacemaker
steroid therapy
seizures (epilepsy)
heart attack
shortness of breath
cancer
diabetes
kidney disease
stroke
arthritis
thyroid disease
Do you have problems with your sinuses or a history of sinus surgery? If yes, please explain.
YES
NO
NOT SURE/MAYBE
Do you have arthritis or pain/problems with any joints in your body? If yes, please explain.
YES
NO
NOT SURE/MAYBE
Are there any conditions or diseases not listed above that you have or have had? If so, what?
YES
NO
NOT SURE/MAYBE
Are there any diseases or medical problems that run in your family? (eg. diabetes, cancer or heart disease)
YES
NO
NOT SURE/MAYBE
Do you smoke or chew tobacco products?
YES
NO
FOR WOMEN ONLY:
Are you pregnant or suspect you may be pregnant? If pregnant, what is the expected delivery date?
YES
NO
NOT SURE/MAYBE
Do you have osteoporosis and/or take osteoporosis medications (eg. Fosamax, Actonel)
YES
NO
NOT SURE/MAYBE
To the best of my knowledge, the above information is correct:
Patient/Parent/Guardian signature:
*Please note that by signing this form, you acknowledge that all applicable fees are due at today’s appointment
**If you are pregnant, or think you may be, please inform the staff prior to having any x-rays.
***Please note by signing this form, you are consenting to the release of your x-rays to both the referring and family dentist.