Yes

1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why? 2. When was your last medical check up? 3. Has there been any change in you general health in the past year? If yes, please 4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, PLEASE LIST
5. Do you have any allergies? PLEASE LIST
6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If 7. Do you have or have you ever had asthma? 8. Do you have or have you ever had any heart or blood pressure problems? 9. Do you have or have you ever had an artificial heart valve, and / or infection of the heart (i.e. invective endocarditis), a heart condition from birth (i.e. congenital heart disease) or heart transplant? 10. Do you have a prosthetic or artificial joint? 11. Do you have any conditions or therapies that could affect you immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy? 12. Have you ever had hepatitis, jaundice or liver disease? 13. Do you have a bleeding problem or bleeding disorder? 14. Have you been hospitalized for any illnesses or operations? IF YES, PLEASE
EXPLAIN.
15. Do you have or have you ever had any of the following? Please circle. chest pain rheumatic fever pacemaker steroid therapy heart attack mitral valve prolapse lung disease diabetes stroke heart murmur tuberculosis stomach ulcers thyroid disease shortness of breath cancer arthritis seizures (epilepsy) kidney disease drug/alcohol dependency osteoporosis medications (e.g. Fosamax, Actonel) 16. Are there any conditions or diseases not listed above that you have or have had? IF
SO, WHAT?
17. Are there any diseases or medical problems that run in your family? 19. Are you nervous during dental treatment? 20. For women only: Are you breastfeeding or pregnant? If pregnant, what is your
To the best of my knowledge, the above information is correct:
Patient/Parent/
GuardianSignature:_____________________________Date:______________________

Personal Information
** PLEASE CHECK OFF how you would like to BOOK and/or RECEIVE confirmation of
appointments**
Dental Knowledge

When was your last Dental visit?
____________________________________
___________________________________
How often do you brush?_______________
N How often_________
Other Have you had any of the following: appliances Does your jaw crack or pop when opened widely? Do you have any difficulty opening or closing your jaw? Do you have any of the following habits? Mouth breathe while awake or asleep Bite your lips or cheeks ______________________________________________________________________

I understand that responsibility for payment of the dental services for myself and my
dependents is mine and I assume responsibility for fees associated with these services.
To the best of my knowledge, the information contained is correct:
Patient/Parent/ Guardian Signature:________________________Date:_____________

Source: http://www.palmerstondental.ca/docs/NewPatientForms.pdf