Medical History Questionnaire

Kutlesa Dental

905-643-5835 | 604 Highway 8

Medical Alert

In Case of Emergency, We Should Notify

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.

1. Are you currently being treated for any medical condition or have you been treated within the past year?
3. Has there been any change in your general health in the past year?
4. Are you taking any medications, non-prescriptions drugs or herbal supplements of any kind?
5. Do you have any allergies?
6. Have you ever had a peculiar or adverse reaction to any medicines or injections?
7. Do you have or have you ever had asthma?
8. Do you have or have you ever had any heart or blood pressure problems?
9. 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?
10. Do you have a prosthetic or artificial joint?
11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
12. Have you ever had hepatitis, jaundice or liver disease?
13. Do you have a bleeding problem or bleeding disorder?
14. Have you ever been hospitalized for any illnesses or operations?
15. Do you have or have you ever had any of the following? Please check all that apply.
16. Are there any conditions or diseases not listed above that you have or have had? If yes, please explain.
17. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?
18. Do you smoke or chew tobacco products?
19. Are you nervous during dental treatment?
20. Are you breastfeeding or pregnant?
21. Do you identify as a patient with a disability? If yes, please explain.

To the best of my knowledge, the above information is correct.

Patient/Parent/Guardian Signature

Date