www.esquiredentalcentres.com - Medical History Questionnaire

Thank you for requesting an appointment with Esquire Dental Centres.
One of our scheduling coordinators will contact you shortly to confirm your appointment time.

If you are a new patient, please fill out and submit your medical history below. If you wish to do this at a later time please access from the Patients Forms tab.
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Medical History Questionnaire

Medical Alert
Select Location*

For North York OfficeFor Pickering OfficeFor Scarborough Office
Tittle*
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Gender
Address (Home)*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Address (Business)

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Occupation
Who referred you to our office?
In case of emergency, we should notify
Name*

First NameLast Name
Relationship*
Day-time phone*
Please enter a valid phone number.
Name of family doctor
Phone or address
(1) Name of medical specialist
Area of specialty
Phone or address
(2) Name of medical specialist
Area of specialty
Phone or address
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.
01. Are you currently being treated for any medical condition, or have you been treated within the past year?*

YesNoNot Sure/Maybe
If yes, please explain?*
02. When was your last medical checkup?
03. Has there been any change in your general health in the past year?*

YesNoNot Sure/Maybe
If yes, please explain?*
04. Are you taking any medications, non-prescription drugs, or herbal supplements of any kind?*

YesNoNot Sure/Maybe
If yes, please list them*
05. Do you have any allergies?*

YesNoNot Sure/Maybe
If yes, please list them using the categories below*
06. Have you ever had a peculiar or adverse reaction to any medicines or injections?*

YesNoNot Sure/Maybe
If yes, please explain?*
07. Do you have or have you ever had asthma?*

YesNoNot Sure/Maybe
08. Do you have or have you ever had any heart or blood pressure problems?*

YesNoNot Sure/Maybe
09. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart(i.e., infective endocarditis), a heart condition from birth (i.e., congenital heart disease), or a heart transplant?*

YesNoNot Sure/Maybe
`10. Do You have a prosthetic or artificial joint?*

YesNoNot Sure/Maybe
11. Do you have any conditions or therapies that could affect your immune system (e.g., leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)*

YesNoNot Sure/Maybe
12. Have you ever had hepatitis, jaundice, or liver disease?*

YesNoNot Sure/Maybe
13. Do you have a bleeding problem or bleeding disorder?*

YesNoNot Sure/Maybe
14. Have you ever been hospitalized for any illnesses or operations?*

YesNoNot Sure/Maybe
If yes, please explain?*
15. Do you have or have you ever had any of the following? Please Select*

Chest pain, anginaRheumatic feverPacemakerSteroid therapySeizures (epilepsy)Heart attackMitral valve prolapseLung diseaseDiabetesKidney diseaseStroke, TIATuberculosisStomach ulcersThyroid diseaseShortness of breathHeart murmurCancerArthritisDrug/alcohol/cannabis use or dependencyOsteoporosis medications (e.g. Fosamax, Actonel)None
16. Are there any conditions or diseases not listed above that you have or have had?*

YesNoNot Sure/Maybe
If yes, please explain?*
17. Are there any diseases or medical problems that run in your family (e.g., diabetes, cancer, or heart disease)?*

YesNoNot Sure/Maybe
18. Do you smoke or chew tobacco products?*

YesNoNot Sure/Maybe
19. Are you nervous during dental treatment?*

YesNoNot Sure/Maybe
20. Are you breastfeeding or pregnant?*

YesNoNot Sure/Maybe
If pregnant, what is the expected delivery date?*

MonthDayYear
21. Do you identify as a patient with a disability?*

YesNoNot Sure/Maybe
If yes, please explain?*
Patient Signature*

Clear
Patient Name*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

Medical History Questionnaire

In case of emergency, we should notify