Medical History Form To serve you as best we can, please fill out your information below. All information will be strictly confidential. Step 1 of 4 25% LinkedInThis field is for validation purposes and should be left unchanged.Patient InformationPatient Name* First Last Patient Email* Date of Birth* Gender* M (male) F (female) X (non-binary) Phone (Home/cell)*Phone (Work)Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Occupation*EmployerEmergency ContactEmergency Contact Name* First Last Emergency Contact Phone*Emergency Contact Relationship*PreferencesPreferred Appointment TimesPlease select a day for each preferred time-slot:MondayTuesdayWednesdayThursdayFriday8am—12pm12pm—3pm3pm—6pm Benefits InformationIf insurance is under your nameBenefits Provider Company Name*Group / Policy Number*Certificate / Subscriber ID*Alberta Health Care Number*Additional Benefits InformationIf applicable, or if insurance is under another nameBenefits Provider Company NameGroup / Policy NumberCertificate / Subscriber IDSubscriber NameSubscriber Date of Birth Medical HistoryFamily Doctor's NameFamily Doctor's Phone NumberLast Medical Check-UpPlease select which of the following you have had in the past, or have at present.Nervous System Chronic Headaches Convulsions / Epilepsy Dizziness / Fainting Depression / Anxiety Trigeminal Neuralgia Chronic Pain Respiratory Asthma / Hay Fever Sinus Problems Difficulty Breathing COPD / Lung Disease Bones / Muscles Arthritis / Rheumatism Artificial Joints / Limbs Osteoporosis Date(s) of any joint replacements*Endocrine Diabetes Hypoglycemia Thyroid / Goiter Heart / Circulatory Rheumatic Fever Heart Murmur Chest Pain / Discomfort Heart Attack / Stroke / TIA Pacemaker Shortness of Breath High Blood Pressure Mitral Valve Prolapse Artificial Heart Valve/Stent Endocarditis Allergies Local Anesthetics Latex Sensitivity Penicillin Aspirin Codeine Any additional allergies?Blood Bruise Easily Anemia Blood Transfusion Bleeding Disorder Excessive Bleeding Prolonged Healing GI System Hepatitis Liver Disease / Jaundice Ulcers Kidney Trouble Specify which type of Hepatitis:*Immune System Radiation / Chemotherapy AIDS / HIV Cancer Autoimmune Disorder Have you ever been hospitalized or had a serious illness?* Yes No If yes, please specify:*Are you being treated for any other medical condition not listed?* Yes No If yes, please specify:*Are you taking any medications, non-prescription drugs, or herbal supplements?* Yes No If yes, please list:Do you use tobacco products?* Yes No If yes, what and how much/often?*Do you use any recreational drugs?* Yes No If yes, what and how much/often?*Are you pregnant?(For females only) Yes No If yes, how many months?*Are you breastfeeding?(For females only) Yes No Are there any diseases or medical problems that run in your family?* Yes No If yes, please specify:*Please indicate anything else we should know about your health: Dental HistoryPrevious Dentist's NamePrevious Dentist's Phone NumberLast Dental Visit*Last Dental X-Ray(s)*How often do your brush your teeth?*How often do you use dental floss?*Have you ever had local anaesthetic (freezing)?* Yes No Were there any complications?* Yes No If yes, please specify:*Do you experience or have any of the following: Bleeding / Soft Gums Unpleasant Taste / Bad Breath Mouth Blisters / Lumps Orthodontics / Braces Clicking / Popping Jaw Jaw Accidents / Injuries Misaligned teeth Teeth Sensitivity (Hot / Cold) Facial Pain Difficulty Chewing / Swallowing Food Catching In Between Teeth Clenching / Grinding Teeth Shifting Teeth Stained Teeth How did you hear about us?* Live Nearby Facebook / Social Media Google / Online Signage Referral Other Let us know who to thank!Please specify:On a scale of 1 to 10, how satisfied are you with your smile?*12345678910Anything specific you'd like to mention about your smile?I confirm the following:* I understand the above information is necessary to provide me with the dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider who may release such information to Blue Quill Dental Centre. I will notify Blue Quill Dental Centre of any change in my health or medication. A Comprehensive Lineup of Dental Care Services All Under One Roof
