Family Dentistry in Maple Medical History Form
We are pleased to welcome you to our practice, and hope to provide you, your family, relatives and friends with the highest quality of dental care.
In order to render the best professional care it is necessary that we become acquainted with the vital information related to each patient. Of course all information is strictly confidential. We appreciate your cooperation in filling out this form carefully and accurately.
Primary Insurance Information
Secondary Insurance Information (if applicable)
Please select yes or no to the following:
Are you presently being treated by a physician?*
Are you taking any medications, pills, drugs, or medicine?
Do you suffer from any allergies (hay fever, latex, etc)?
Allergies: Have you ever had a reaction to any of the following?*
Have you ever been warned against using any other medications?
Have you ever taken prolonged medical or non-medical drugs?
Do you bruise easily or have prolonged bleeding?
Have you ever fainted, had shortness of breath, or chest pains?
Women, are you currently pregnant?
Are you using birth control?
Do you have any of the following:
Is there anything else we should know about your health?