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New medicalhistoryquestionnaire[1] 2

MEDICAL HISTORY QUESTIONNAIRE
NAME: Mr./Miss/Mrs./Ms./Dr.
____________________________________________ DATE OF BIRTH: (DAY/MONTH/YEAR):
_________________________________________ HOME ADDRESS:
__________________________________________________
IN CASE OF EMERGENCY, WE SHOULD NOTIFY:
CITY: __________________________________________
NAME: ________________________________________________
POSTAL CODE: __________________________________
_________________________________
HOME: _____________________________________________________
DAY-TIME PHONE: _________________________________
CELL: ___________________________________ _______
FAMILY PHYSICIAN: _____________________________
WORK: ___________________________________ _______
PHONE: ________________________________________
EMAIL: __________________________________________
WHO REFERRED YOU:
EMPLOYER: ______________________________ _______
________________________________________________
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.
1. Are you being treated for any medical condition at the present or have you been treated within the past year?
If so, why?

Not Sure/Maybe
____________________________________________________________________________________________________________________ 2. When was your last dental check up?
____________________________________________________________________________________________________________________
3. Has there been any change in your general health in the past year? If yes, please explain.
Not Sure/Maybe
____________________________________________________________________________________________________________________
4. Do you currently have any of the following? Please Circle
Coughing High fever Open Sores Vomiting Diarrhea
5. Are you taking or have you taken any medications, non-prescription drugs or herbal supplements
in the past 6 months? (e.g. Vitamins, Dietary supplements, Herbal supplements)

N o t S u r e /
Maybe
If yes, please list…

_____________________________________________________________________________________________________________________ 5b: Have you used cocaine, marijuana or any other drugs in the past year? Please List…
Yes No Not Sure/Maybe

_____________________________________________________________________________________________________________________

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

Not Sure/Maybe
a) medications
b) latex/rubber products
c) other e.g. hayfever, foods
_______________________________________________________________________________________________________________

6b: Have you been diagnosed with any new allergies in the past year?
Not Sure/Maybe
_______________________________________________________________________________________________________________
7. Have you ever had a peculiar or adverse reaction to any medicines or injections?
Not Sure/Maybe
If yes, please explain.
_____________________________________________________________________________________________________________ 8. Do you have or have you ever had Asthma?
Not Sure/Maybe
_____________________________________________________________________________________________________________
9. Do you have or have you ever had any Heart or Blood Pressure problems?
Not Sure/Maybe
______________________________________________________________________________________________________________
10. Do you have or have you ever had an artificial heart valve, a history of infective endocarditis, a heart transplant
or a congenital heart defect?
Please List:

______________________________________________________________________________________________________________ 10b: Do you have a pace maker?
Yes No Not Sure/Maybe

11. Do you have a prosthetic or artificial joint?

Not Sure/Maybe
_____________________________________________________________________________________________________________ 12. Have you ever been advised by your doctor to take antibiotics before dental treatment?

Not Sure/Maybe
______________________________________________________________________________________________________________ 13. Do you have any conditions or therapies that could affect your immune system: Please Circle
Leukemia AIDS HIV infection Radiotherapy Chemotherapy

14. Have you ever had hepatitis A, B, or C, jaundice or liver disease?

Not Sure/Maybe
_______________________________________________________________________________________________________________ 15. Do you have a bleeding problem or bleeding disorder?
Not Sure/Maybe
_______________________________________________________________________________________________________________ 16. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.

Not Sure/Maybe
_______________________________________________________________________________________________________________ 17. Do you have or have you ever had any of the following? Please circle.
chest pain, angina
shortness of breath
steroid therapy
seizures(epilepsy)
kidney disease
heart attack
prosthetic heart valve
lung disease
diabetes
tuberculosis
stomach ulcers
thyroid disease
arthritis
diet pill therapy drug/alcohol dependency
18. Are there any conditions not listed above that you have or have had? If so, what?

Not Sure/Maybe
____________________________________________________________________________________________________________ 19. Are there any diseases or medical problems that run in your family?
(e.g. diabetes, cancer or heart disease)
Not Sure/Maybe
_____________________________________________________________________________________________________________ 20. Are you taking or have you taken Bisphosphonate Therapy (bone density medication)? If so, how long?
(E.g. Actonel, Boniva, Fosamax, Skelif, Didronel)

Not Sure/Maybe
_____________________________________________________________________________________________________________ 21. Do you smoke or chew tobacco products?
Not Sure/Maybe
_____________________________________________________________________________________________________________ 22. Are you nervous during dental treatment?
Not Sure/Maybe
_____________________________________________________________________________________________________________ 23. Have you ever had difficulty becoming anesthetized (numb) for dental procedures?

Not Sure/Maybe
_____________________________________________________________________________________________________________ 24. For Women Only: Are you pregnant or breast feeding? If pregnant, what is the expected delivery date?

Not Sure/Maybe
_____________________________________________________________________________________________________________ To the best of my knowledge, the above information is correct:
PATIENT/PARENT/GUARDIAN SIGNATURE: ____________________________ ______________ DATE: ____________________________
I UNDERSTAND and agree that I AM RESPONSIBLE for payment of all dental services provided to me and/or my
dependents. I hereby assign my benefits, payable from claims submitted electronically or manually, to Nose Creek Dental
Centre and authorize payment directly to the providing dentist.
Please be advised that it is your responsibility to understand your Insurance Guidelines.
________________________________________ ______________________________
Signature of Patient/Parent or Guardian
INSURANCE INFORMATION (Primary Plan)
Name of Insured: __________________________________
D.O.B. Day ________ Month ________ Year ________
Address: _______________________________________________ Postal Code: __________________
Home Phone: __________________ Work: _________________ Ext: ______ Cell: ______________________
Name of Employer: ___________________________________ Name of Ins. Company: _________________
Group/Policy No. ________________ Cert./ID No. ____________________ Cov. No. ___________________
INSURANCE INFORMATION (Secondary Plan if applicable)
Name of Insured: ___________________________________
D.O.B. Day ________ Month ________ Year ________
Address: _________________________________________________ Postal Code: __________________
Home Phone: __________________ Work: _________________ Ext: ______ Cell: _______________________
Name of Employer: ___________________________________ Name of Ins. Company: _________________
Group/Policy No. ________________ Cert./ID No. _____________________ Cov. No. ______________________
INSURANCE INFORMATION (Third Plan if applicable)
Name of Insured: ___________________________________
D.O.B. Day ________ Month ________ Year ________
Address: ____________________________________________________ Postal Code: __________________
Home Phone: __________________ Work: _________________ Ext: ______Cell: ________________________
Name of Employer: ___________________________________ Name of Ins. Company: __________________
Group/Policy No. _________________ Cert./ID No. _____________________ Cov. No. _________________
CONSENT FOR COLLECTION AND RELEASE OF INFORMATION
We are committed to protecting the privacy of our patient’s personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances in this form, we also collect, use and disclose personal information when permitted or required by We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, email addresses, credit card information, social insurance numbers and private dental insurance information. (Collectively referred to as “Contact Information”). Contact information is collected and used for the following purposes: To invoice patients for dental services, to process credit card payments, and to collect unpaid accounts.
To process claims for payment or reimbursement from third-party health benefit providers and insurance companies.
To send reminders to patients concerning the need for further dental examination or treatment.
To send patients informational material about our dental materials.
To follow up with treatment and/or customer service.
Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patients Financial information may be collected in order to make arrangements for the payment of dental services or to provide a form of We collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as “Medical Information”). Patient’s medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.
Patients Medical Information is disclosed for the following purposes: To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.
To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining a second opinion.
To other dentists and dental specialists, if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment.
To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion.
To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.
If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.
Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest.
I consent to the collection, use and disclosure of my personal information as set out above.
_________________________ ______________________________ _________________________

Source: http://www.nosecreekdental.ca/wp-content/uploads/2010/11/Nose-Creek-Medical-History.pdf

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