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Medical Questionnaire
Golden Smile Dental Clinic
2026-01-26T04:13:59+00:00
Medical Questionnaire
Full Name
*
Date of Birth:
*
Have you ever had a serious illness requiring hospitalization or extensive medical care?
*
Select
Yes
No
If yes, please specify
Please list any prescription or non-prescription medications you take regularly.
*
Select
Yes
No
If yes, please specify
Do you have any allergies: i.e. Penicillin, Asthma, Skin rash, Food allergic or latex allergies?
*
Select
Yes
No
If yes, please specify
Do you have or have you ever had any of the following?
*
Heart murmur/ heart disease
Stomach/intestinal problem
Joint replacement (Hip, Knee etc)
High/low blood pressure
Kidney disease
Liver disease
Epilepsy/ Seizures
Drug/alcohol addiction
Thyroid disease
Arthritis
Scarlet or rheumatic fever
AIDs/ HIV virus positive
Tuberculosis
Stroke
Hepatitis A/B/C
Cancer
Diabetes Type I or II
Lung disease
Mental disease
None of Above
Do you bruise easily or bleed abnormally?
*
Select
Yes
No
If yes ,please specify
Do you have any blood disorder such as anaemia, thalassaemia(Major, Minor)?
*
Select
Yes
No
If yes, please specify
Do you experience shortness of breath or chest pain when walking or climbing stairs?
*
Select
Yes
No
If yes, please specify
Have you had any organ transplants or medical implants?
*
Select
Yes
No
If yes, please specify
Is there anything else about yourself that the doctor should know about?
*
Select
Yes
No
If yes, please specify
Women only - Are you pregnant?
Select
Yes
No
If yes, what month are you in?
Dental History
Reason for today's visit
*
Regular checkup
Cleaning
Toothache
Other
If other, please specify
How frequently do you see your dentist?
6 Months
Yearly
Other
If other, please specify
Are any of your teeth sensitive to
Cold
Sweet
Heat
Other
If other, please specify
Do you grind or clench your teeth during the day or night?
Yes
No
Other
If other, please specify
Do you smoke?
Cigarrettes
Cigars
Marihuana
Other
If other, please specify
General Release
*
I, the undersigned, certify that I have provided accurate and complete personal and medical - dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical - dental history. Should there be any change in either my health status or any other information I have provided, I will advise the dental office. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within guidelines of the policy.
Signature Date
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Signature
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