Lenga Perio™ | Medical History Questionnaire

Name: *

First

Last

Date of Birth *//

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number (Home): *

Phone Number (Work):

Email *

Email

Confirm Email

Who referred you to our office?: *

Your General Dentist: *

Your Occupation:

In case of emergency, we should contact: *

Relationship: *

Day-time Phone: *

Name of Family Doctor: *

Doctor's Phone Number or Address: *

Current Height and Weight: *

Primary Insurance Carrier:

Policy Number:

ID Number:

Name of Insured (if different from yourself):

D.O.B. of Insured (if different from yourself)://

Secondary Insurance Carrier:

Policy Number:

ID Number:

Name of Insured (if different from yourself):

D.O.B. of Insured (if different from yourself)://

Are you being treated for any medical condition at the present, or have you been treated within the past year. *

Yes
No
Not sure/maybe

If yes, why?

When was your last medical checkup? *//

Has there been any change to your general health in the past year? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you taking any medications, non-prescription drugs or herbal supplements of any kind? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you allergic to any medications? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you allergic to latex/rubber products? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have any other allergies (e.g. hay fever, foods)? *

Yes
No
Not sure/maybe

If yes, please explain:

Have you ever had a peculiar or adverse reaction to any medications, medicines or injections? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have, or have you ever had asthma? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have, or have you ever had any heart or blood pressure problems? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have, or have you ever had a heart murmur, mitral valve prolapsed or rheumatic fever? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have a prosthetic or artificial joint? *

Yes
No
Not sure/maybe

If yes, please explain:

Have you ever been advised by your doctor to take antibiotics before dental treatment? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have any conditions or therapies that could affect your immune system (leukemia, HIV/AIDS, radiotherapy, chemotherapy)? *

Yes
No
Not sure/maybe

If yes, please explain:

Have you ever had hepatitis, jaundice or liver disease? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have a bleeding disorder, or bleed excessively? *

Yes
No
Not sure/maybe

If yes, please explain:

Have you ever been hospitalized for any illness or operations? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have, or have you ever had any of the following? Please check all that apply:

Are there any conditions or diseases not listed above that you have, or have had in the past? *

Yes
No
Not sure/maybe

If yes, please explain:

Are there any diseases or medical problems that run in your family (diabetes, cancer, heart disease)? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you smoke or chew tobacco products? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you nervous during dental treatment? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you pregnant or currently breast feeding? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you taking any medications, oral or injection, past or present for osteoporosis? *

Yes
No
Not sure/maybe

If yes, please explain:

Is there any additional information regarding your health that you need to share? *

Yes
No
Not sure/maybe

If yes, please explain:

Rate your smile from 1-5 *

What do you like the most about your smile? *

What would you like to fix about your smile? *

To the best of my knowledge, the above information is correct: *

I agree

Signature *

Date *//

Medical History Questionnaire

55 St. Clair Ave. W. #127,
Toronto, ON M4V 2Y7

info@stclairperio.ca

416-929-9009

416-929-4866

Mon-Thurs 8am-4:30pm
Fri 7:30am-1:30pm

Medical History Questionnaire

55 St. Clair Ave. W. #127,Toronto, ON M4V 2Y7

info@stclairperio.ca

416-929-9009

416-929-4866

Mon-Thurs 8am-4:30pmFri 7:30am-1:30pm

55 St. Clair Ave. W. #127,
Toronto, ON M4V 2Y7

Mon-Thurs 8am-4:30pm
Fri 7:30am-1:30pm