Belleville ADULT Medical/Dental History Form

  • Medical & Dental History

    Please take a moment to tell us about your medical and dental history so that we can serve you as effectively as possible. Your information is being stored securely.
  • Date*
     - -
     :

  • Patient Info

  • Date of Birth
     - -
  • Biological Sex*

  • NOTICE

    Please ensure you have been given the correct form!

    This form is intended for use by adults only. If you need the form for your child/dependent, please contact the Belleville FDC Office at (613) 961-7050.

  • General Health

  • Overall, would you consider yourself to be in good health?*
  • Within the past year, have there been any changes in your general health?*
  • Approximately when was your last full physical exam?
     - -
  • Are you currently under the care of a physician due to a specific condition?*
  • Have you been hospitalized for surgery or illness within the last five (5) years?*
  • Are you currently taking any prescription medications or supplements?*
  • Do you consume recreational drugs?*
  • Do you smoke?*
  • Do you drink alcohol?*
  • Are you pregnant?*
  • When is the due date?*
     - -
  • Are you taking birth control medication?*

  • Medical Conditions

  • Have you been treated for or told you have any of the following:*
  • Ga
  • Have you been diagnosed with any other disease or condition not mentioned above?*
  • Is there anything else about your health that we should be aware of?*
  • Would you like to speak to the Doctor privately about anything?*

  • Dental Info

  • Was your last New Patient Exam done at this office?
  • If not, when was it?
     - -
  • Was your last cleaning done at this office?
  • If not, when was it?*
     - -
  • Was your last set of X-Rays done at this office?
  • If not, when was it?*
     - -
  • How often do you brush your teeth?*
  • How often do you floss your teeth?*
  • How often did you see your previous dentist/hygienist?*
  • Have you ever been told to take antibiotics before receiving dental treatment?*
  • Have you ever had orthodontic treatment?*
  • Do your gums bleed or hurt?*
  • Are your teeth sensitive to hot or cold temperatures?*
  • Do you clench or grind your teeth?*
  • Have you ever been fitted for a night guard?*
  • Are your teeth currently causing you any pain or discomfort?*
  • Do you have any loose or chipped teeth?*
  • Have you ever experienced heavy bleeding following extractions?*
  • Have you ever had complications after dental treatment?*
  • Do you have any tooth replacements (dental implants, dentures/partials, or bridges)?*

  • Final Page

  • Authorization

  • I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

    I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

    I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practicioners. I authorize my insurance carrier to submit payment directly to the dentist or dental practice and for it to be applied directly to any outstanding balance on my account.

    I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agreeto be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

  • Date*
     - -

  • FOR OFFICE USE ONLY

  • Dentist Signature Date*
     - -
  • Should be Empty: