BURLINGTON DENTAL CLINIC

MEDICAL HISTORY

NAME: ______

POSTALADDRESS: ______

TEL:(H)______(W)______MOBILE ______

EMAIL:

PREFERRED METHOD OF CONTACT: ______

Date Of Birth______Sex:____Height:_____Weight:___Occupation: ______

SINGLE: ____MARRIED: _____ OTHER NAME OF SPOUSE: ______

CLOSEST RELATIVE: ______PHONE: ______

Who referred you to this Practice?______

In the following questions, circle Yes/No, whichever applies. Your answers are for our records only and will be considered confidential.

I Are you in good health? Yes/No.

II Has there been any change in your general health in the past year? Yes/No. III. Your last physical examination was on ______

IV. Are you under the care of a physician? Yes /No If so, what is the condition being treated? ______

Name & address of your physician ______

V. Have you had any serious illness or operation? Yes/No If so, what? ______

VI. Have you been hospitalised or had a serious illness within the

last five years? Yes/No If so, what was the problem? ______

VII. Do you have or have you had any of the following diseases or problems?

a. Damaged heart valves or artificial heart valves. Yes/No

  1. Congenital heart lesions. Yes/No
  2. Cardiovascular disease (heart trouble, heart attack, coronary

insufficiency, coronary occlusion, high blood pressure,

arteriosclerosis (stroke)? Yes/No

1.Do you have pain in your chest upon exertion? Yes/No

2.Are you ever short of breath after mild exercise? Yes/No

3.Do your ankles swell? Yes/No

4.Do you get short of breath when you lie down, or do you

require extra pillows when you sleep? Yes/No

5.Do you have a cardiac pacemaker? Yes/No 6.Have you ever been told that you have a heart murmur? Yes/No 7.Did you ever have rheumatic fever? Yes/No

d. allergy? Yes/No

e.Sinus trouble Yes/No

f. Asthma or hay fever? Yes/No

  1. Hives or skin rash? Yes/No
  2. Fainting spells or seizures? Yes/No
  3. Diabetes? Yes/No

1.Do you have to urinate more than six times a day? Yes/No 2. Are you thirsty much of the time? Yes/No

3. Does your mouth frequently become dry? Yes/No

J. Hepatitis, jaundice or liver disease? Yes/No

K. Arthritis? Yes/No

L. Inflammatory rheumatism (painful swollen joints). Yes/No

M. Stomach ulcers? Yes/No

N. Kidney trouble? Yes/No

O. Tuberculosis? Yes/No

Please Turn Over

P. Do you have a persistent cough or cough up blood? Yes/No

Q. Low blood pressure? Yes/No

R. Venereal Disease? Yes/No

S. Any Other? Yes/No

VIII. Have you had any abnormal bleeding associated with previousYes/No

extractions, surgery, or trauma?

  1. Do you bruise easily? Yes/No
  2. Have you ever required a blood transfusion? Yes/No

If so please explain the circumstances:

X. Do you have any blood disorder such as anaemia? Yes/No

XI. Have you had surgery or x-ray treatment for a tumour, growth,

or other condition of your head or neck? Yes/No XII. Are you taking any drug or medicine? Yes/No

If so what?______

XIII Are you taking any of the following:

  1. Antibiotics or sulfra drugs? Yes/No
  2. Anticoagulants (blood thinners)? Yes/No
  3. Medicine for high blood pressure? Yes/No
  4. Cortisone (steroids)?Yes/No
  5. Tranquillisers? Yes/No
  6. Antihistamines? Yes/No
  7. Aspirin? Yes/No
  8. Insulin, tolbutamide (Rastinon) or similar? Yes/No
  9. Digitalis or drugs for heart trouble?Yes/No
  10. Nitroglycerin? Yes/No
  11. Oral contraceptive or other hormonal therapy? Yes/No

Are you allergic or have you had any adverse reaction to:

a. Local anaesthetics?Yes /No

b. Penicillin or other antibiotics?Yes/No

c. Sulfra drugs? Yes/No

d. Barbiturates, sedatives, or sleeping pills?Yes/No

e. Aspirin? Yes/No

f. Iodine? Yes /No

g. Codeine or other narcotics? Yes /No

h. Other? Yes/No

Have you had any serious trouble associated with any previous

dental treatment? Yes/No

If so, explain______

Do you have any disease, conditions or problems not listed above that we should know about? Yes/No

If so, explain______

Are you in any situation, which exposes you regularly to

x-rays or other ionising radiation?Yes/No

Are you wearing contact lenses?Yes/No

Do you now, or have you ever smoked? Yes/No

Women Only

Are you pregnant? Yes/No

Do you have any problems related with you menstrual period? Yes/No

Are you nursing? Yes/No

Signature of Patient______Date ______