Medical History Form

Health Insurer
Full name *
Date of Birth *
Address *
Home phone
Work phone
Email *
Emergency contact name
How were you refered here?
When was last visit to a dentist?
Main concern for visit today
Are your teeth sensitive to:

Do your gums bleed when brushing or flossing?
Have you had any complications during or following dental treatment?
Have you had prolonged bleeding after tooth removal or dental surgery?
Do you grind your teeth or clench your jaw?
Is there anything you would like to change about your teeth or their appearance?
Who is your General Practitioner?
Are you currently being treated for a medical condition?
Are you taking any medications or supplements at present, both prescribed and over the counter?
Do you currently have, or have you ever had any of the following medical conditions?
Do you have allergies? Please list:
Do you smoke?
For women, are you pregnant or undergoing fertility treatment?

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