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
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.Format: (000) 000-0000.
Address (Business)

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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?
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?
If yes, please explain?
04. Are you taking any medications, non-prescription drugs, or herbal supplements of any kind?
If yes, please list them
05. Do you have any allergies?
If yes, please list them using the categories below
06. Have you ever had a peculiar or adverse reaction to any medicines or injections?
If yes, please explain?
07. Do you have or have you ever had asthma?
08. Do you have or have you ever had any heart or blood pressure problems?
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?
`10. Do You have a prosthetic or artificial joint?
11. Do you have any conditions or therapies that could affect your 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 ever 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 Select
16. Are there any conditions or diseases not listed above that you have or have had?
If yes, please explain?
17. Are there any diseases or medical problems that run in your family (e.g., diabetes, cancer, or heart disease)?
18. Do you smoke or chew tobacco products?
19. Are you nervous during dental treatment?
20. Are you breastfeeding or pregnant?
If pregnant, what is the expected delivery date?

MonthDayYear
21. Do you identify as a patient with a disability?
If yes, please explain?
Patient Signature
Patient Name

First NameLast Name
Date

MonthDayYear
Should be Empty:

Medical History Questionnaire

In case of emergency, we should notify