South Ancaster Family Dental

Medical History Form

21 Panabaker Drive, Unit 4, Ancaster, Ontario L9G 0A4      905-304-9555

Welcome to South Ancaster Family Dental

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 in the entire form.

Medical Alert:
Patient's Name:
Family Doctor:
Medical Specialist:

Are you currently being treated for any medical condition or have you been treated within the last year?

Health Card #:
When was your last medical checkup?

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

If yes, please explain.

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

If yes, please list them.

Do you have any allergies? If yes, please list them using the categories below:

Medications
Latex/Rubber Products
Other (e.g. Hay Fever, seasonal/environmental, foods)

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

If yes, please explain.

Do you have or have you had asthma?

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

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?

Do you have a prosthetic or artificial joint?

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

Have you ever had hepatitis, jaundice or liver disease?

Do you have a bleeding problem or bleeding disorder?

Have you ever been told by your Doctor, that you require Anti-Biotics prior to routine dental treatment?

If yes, why?

Have you ever been hospitalized for any illnesses or operations?

If yes, please explain.

Do you have or have you ever had any of the following? Please check.

YesNo YesNo
AIDS/HIV Radiation Treatments
Blood Thinners Hepatitis A/B/C
Chest pain Rheumatic fever
Pacemaker Steroid therapy
Heart attack Mitral valve prolapse
Lung disease Diabetes
Stroke, TIA Tuberculosis
Stomach ulcers Thyroid disease
Heart murmur Cancer
Arthritis Drug/Alcohol/Cannabis use or dependency
Seizures (Epilepsy) Kidney disease
Shortness of breath Osteoporosis medications (e.g. Fosamax, Actonel)

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

If yes, please explain.

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

Do you smoke or chew tobacco products?

Are you nervous during dental treatment?

Are you breastfeeding or pregnant?

If pregnant, what is the expected delivery date?

Do you identify as a patient with a disability?

If yes, please explain.

Patient/Parent/Guardian Signature: