Medical History Form

If any questions, please call

Telephone (905) 688-3610

Patient Information

First name

Last name

Home phone number

Cell phone number

Street Address

City

Postal Code

Email address

Date of birth

Employer

Family MD

Dr. Phone #

Pharmacy Name

Pharmacy Phone #

Emergency Contact Information

Name

Phone Number

Insurance Information

Name of insurance policy holder

Date of Birth of Insurance Policy Holder

Policy/plan #

Certificate #

Employer Name

Insurance Company Name

Health History

Are you in good medical condition?

Yes No

Has your general health changed in past year?

Yes No

Are you currently under the care of a physician?

Yes No

Date of last physical examination?

Are you currently under the care of any medical specialists (cardiologists, etc.)

Yes No

If yes, please list name and contact number for each medical specialist

Please check if any of the following respiratory system conditions apply to you:

Asthma

Emphseyma

Bronchitis/pneumonia

Tuberculosis

Persistent cough

Difficulty breathing

COPD

Please check if any of the following blood conditions apply to you:

Cerebrovascular accident (stroke)

Anemia

Hemophilia/clotting disorder

Leukemia

Blood transfusion history

Immunodeficincy (e.g. HIV)

TIA

Other Condition - Please Specify

Medications

Please list any medications (include herbal/non-pharmaceutical) and dosage

Do you have any of the following allergies?

Penicillin

Aspirin

Codeine

Latex

Local anesthetic

Percocet

Sulpha

Valium

Other Allergies - Please Specify

Do you carry an Epi-Pen?

Yes No

Have you ever Required Premedication (such as antibiotics) prior to Dental Appointments?

Yes No

Have you ever had a serious illness/operation/hospitalization?

Yes No

If yes, please describe:

Do you smoke, vape, or use tobacco products?

Yes

Not sure /maybe

If yes, what do you use and how often?

Do you use marijuana or other recreational drug?

Yes

Not sure /maybe

If yes, what do you use and how often?

Please indicate any diseases that run in your family

Do you identify as a patient with a disability?

Yes

Not sure/maybe

If yes, please explain

Please list any other pertinent medical history details

For Women Only - check any that apply

Pregnant

Nursing

Birth control medication

Hormone Replacement

Dental History

Name of Previous Dentist

Date of last dental visit

Date of last dental x-rays

Date of last dental cleaning

Are you currently under the care of any dental specialist (orthodontist/periodontist)?

Do you have or have you ever had any of the following?

Dentures

Braces

Periodontal (gum) treatments

Difficult extractions

Jaw surgery

Nightguard appliance

Are you apprehensive about dental treatment?

Yes No

Your Smile

If you could change your smile you would...

Make your teeth brighter

Make your teeth straighter

Close spaces

Replace black metal fillings with natural, tooth colored fillings

Repair chipped teeth

Replace missing teeth

Have a smile makeover

Replace old crowns that don't match

Today's Date

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Dr. Kevin J. Boyce

Dr. Kevin Boyce is a practicing general dentist in St. Catharines, Ontario. He is an active member of the Ontario Dental Association and is past president of the Niagara Peninsula Dental Association.

(905) 688-3610
boycedentistry.com
196 Ontario Street, St. Catharines, Ontario, L2R 5L1, Canada