New Patient Medical History


Medical History              Earlsbridge Dental

Please check any of the following that apply to you:

Privacy Information

I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge and have not knowingly omitted any information. This information has been reviewed with me. If required, I consent to my physician being contacted regarding any specific medical questions. I authorize the dentist and his/her auxiliary staff to perform necessary diagnostic procedures and treatment as required to achive a proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided.

AIDS                ☐ Drug addiction                          HIV positive                   Respiratory problems

Allergies, seasonal              Emphysema                             HPV                                   Rheumatic fever

Anemia                                    Excessive bleeding                Jaundice                          Rheumatism

Arthritis                                   Fainting                                      Jaw joint pain                Scarlet fever

Artificial heart valve           Glaucoma                                  Kidney disease              Seizures

Artificial joints                       Heart conditions/surgeries Liver disease                  Snoring/Sleep apnea

Asthma                                     Low blood pressure               Stomach problems      Blood disease
Mitral valve prolapse           Stroke                                         Bruise easily                   Nervousness/Depression
Thyroid disease                     Cancer                                         Hepatitis A                      Pacemaker
Tuberculosis                           Chemotherapy                         Hepatitis B                      Ulcers

Consent for Collection, Use and Disclosure of Personal Information

I agree that Earlsbridge Dental has obtained informed consent from me with respect to the collection, use and disclosure of my personal health Information. I have been provided with a copy of the consent form and agree that personal information may be collected, used and disclosed as set out in the Privacy Policy at this dental office and is in accordance with the Personal Health Information Protection Act, 2004

Diabetes Hepatitis C Pregnant currently Venereal diseases

Dizziness High blood pressure Radiation (head/neck) Other

Do you have any of the following allergies?

Aspirin Erythromycin Percodan Penicillin

Date: ____________________ Signature: ________________________________________

Codeine Nitrous oxide Latex Sulpha

Darvon Valium Local anesthetic Other __________

Have you ever had a joint replacement? Yes No If yes, when? ___________________________________

Has your physician ever told you to take antibiotics prior to dental procedures? Yes No If so, why? __________________________________________________________________________

Have you ever experienced complications following a medical or dental procedure? Yes No

If yes, please describe. ________________________________________________________________

Is there anything else you think we should know regarding your medical history? Yes No

If yes, please describe. ________________________________________________________________

Are you currently under a physician’s care? Yes No

If yes,what for? _________________________ Physician’s Name: _______________ Phone Number: ______________

Are you taking any medications? Yes No

If yes, please specify _________________________________________________________________