Web Form - Keele Sheppard Dentistry

Medical/ Dental History Form

MEDICAL ALERT:

Personal Information

First Name:

Middle Name:

Last Name:

Gender Identity:

WomanManOtherPrefer Not to Say

Date of Birth:

Home Address:

Cell Phone:

Home Phone:(Optional)

Email Address:

Name of Parents/ Guardian (if under 18 or under guardianship):

Address of Parents / Guardian (if not same as above):

Phone Number of Parents / Guardian:(if not same as above):

Emergency Contact Name:

Relationship:

Contact Number:

Name of Family Physician:

Contact Number of Family Physician:

Email of Family Physician:

Fax Number:

Name of First Medical Specialist (Optional):

Area of Specialty:

Contact Number:

Name of Second Medical Specialist (Optional):

Area of Specialty:

Contact Number:

Fax Number:

Pharmacy Name:

Pharmacy Contact Number:

Pharmacy Email:

Fax Number:

Do you have insurance coverage?

How did you come to know about us? (This information helps us better serve our community and thank the person/ source who referred us to you.)

Medical History Questions

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

YesNoNot Sure

2. When was your last complete medical examination?

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

YesNoNot Sure

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

YesNoNot Sure

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

YesNoNot Sure

6. Have you ever had an adverse reaction to dental freezing, general anaesthetic, penicillin, codeine, aspirin, or other drugs? (circle those that apply)

YesNoNot Sure

7. Do you have a prosthetic heart valve or wear a pace maker?

YesNoNot Sure

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

YesNoNot Sure

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

YesNoNot Sure

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

YesNoNot Sure

13. Are you on medications or injections for osteoporosis? (e.g. Fosamax, Actonel, Prolia)

YesNoNot Sure

14. Have you been told by your medical doctor that you need to take antibiotics before your dental treatment?

YesNoNot Sure

15. Do you have or have you ever had any of the following?*

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

YesNoNot Sure

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

YesNoNot Sure

18. Do you suffer from canker sores or cold sores?

YesNoNot Sure

19. Have you ever fainted? What were the circumstances?

YesNoNot Sure

20. Have you had any organ transplants or joint replacements? If yes, when?

YesNoNot Sure

21. Do you currently use injectable medications for diabetes weight management or metabolic conditions whether prescribed or non-prescribed?
( e.g: ozempic, insulin, wegovy, saxenda)

YesNoNot Sure

For WOMEN ONLY:

22. Are you pregnant? If yes, how many months?

YesNoNot Sure

23. Are you breastfeeding?

YesNoNot Sure

Dental History Questions

24. Are you nervous during dental treatment?

YesNoNot Sure

25. Have you ever had a negative dental experience?

YesNoNot Sure

Periodontal History:

26. Do you feel that you have a bad taste in your mouth?

YesNoNot Sure

27. Does food routinely get wedged between your teeth?

YesNoNot Sure

28. Does your mouth tend to be dry?

YesNoNot Sure

29. Are your parents or siblings missing any of their natural teeth?

YesNoNot Sure

Habits:

30. Do you smoke tobacco, cigars or cigarettes? Recreational smoking? (circle all that apply)

YesNoNot Sure

31. Do you chew on pencils, gum, ice cubes, or popcorn kernels? Etc. (circle all that apply)

YesNoNot Sure

32. Do you bite your fingernails, pins, or use a pipe? Etc. (circle all that apply)

YesNoNot Sure

33. Do you drink coffee, tea, or cola drinks?

YesNoNot Sure

34. Do you bite your lips or cheeks regularly?

YesNoNot Sure

35. Do you breathe through your mouth when awake or asleep?

YesNoNot Sure

36. Are you aware if you snore during sleep?

YesNoNot Sure

37. Do you participate in any sports?

YesNoNot Sure

Aesthetics:

38. Are you satisfied with the appearance of your teeth and smile?

YesNoNot Sure

39. Would you be interested in knowing about veneers, bonding, tooth whitening, implants, ortho, Invisalign, and other cosmetic options?

YesNoNot Sure

40. On a scale of 1 to 5, please rate your current dental health. Excellent

Signatures

Patient Signature:

Date:

Dentist Signature:

Date:

Name of Parent/ Legal Guardian (for minor patients that are under the age of 18)

Signature of Parent/ Legal Guardian:

Dentist Notes:

Your Initials: