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Archibald Dental Practice | Medical History in Ontario



Archibald Dental Practice

                      Ingrid Mack Cruz D.D.S

                 Erick Esmenjaud D.D.S.

call us (909) 947-0670


Family Dentistry

and Orthodontics


 (909) 947-0670

fax (909) 673-0527

[email protected]


Medical History



HEALTH HISTORY                                           Name_______________________________

 I.   Check Appropriate Answers: (Leave blank if you do not understand the question)

Yes     No

                     1.  Is your  general  health  good?_______________________________________________________

               2. Has there been a change in your health within the last year?___________________________

                3. Have you been hospitalized or had a serious illness in the last three years?_______________________

                   Please explain________________________________________________

                4. Are you being treated by a Physician now?___________________________________________________

                   Please explain_____________________________________________________________

                   Date of last general exam ____/_____/_______Date of last Dental exam____/____/____

              5.   If yes to 4 above, name of  Medical Doctor___________________Phone Number (_____)__________
              6.  Have you had  problems with prior dental  treatment?

                    Please explain___________________________________________________________________

               7. Are you in pain now ?    Explain_______________________________________________________________________________

        II.  Have You Experienced:

      YES      NO        8.    Chest pain (angina) ?                                                       YES      NO    19.  Dizziness?               

       YES      NO        9.   Swollen  ankles                                                                  YES      NO    20. Ringing in the ears?

       YES     NO        10.    Shortness of breath?                                                       YES     NO     21.   Headaches?

        YES    NO       11.   Recent weight loss, fever,  night sweat?                         YES     NO      22. Fainting spells?

         YES    NO      12.   Persistent cough, Coughing up blood?                             YES      NO      23.  Blurred vision?

          YES    NO     13.   Bleeding problems, bruising easily?                                   YES    NO       24. Seizures?     

         YES    NO     14.  Sinus problems?                                                                  YES      NO     25. Excessive thirst?

         YES     NO      15.  Difficulty swallowing ?                                                       YES     NO       26. Frequent urination?

         YES     NO      16.  Diarrhea, constipation, blood in stools ?                             YES   NO       27. Dry  mouth?

        YES    NO       17.  Frequent vomiting,  nausea?                                              YES   NO         28. Jaundice ?

       YES     NO        18.  Difficulty urinating, blood in urine ?                                   YES   NO          29. Joint pain, stiffness?

         III.  Do you Have Or Have You Had:

           YES     NO    30. Heart disease? Explain____________________               YES     NO    41. AIDS or ARC?

           YES    NO     31. Heart attack?   Explain____________________                YES     NO   42.  HIV  positive

          YES  NO       32. Heart murmur?                                                                     YES     NO   43.  VD (syphilis or  gonorrhea) ?

          YES    NO     33.High  Blood pressure?                                                            YES    NO   44.  Herpes?

          YES   NO     34.  Stroke, hardening of arteries?                                             YES   NO    45. Skin diseases?

          YES   NO       35. Rheumatic fever?                                                                  YES  NO       46. Eye disease?            

          YES   NO     36.  TB, emphysema, other lung diseases?                                  YES   NO    47. Anemia

          YES   NO      37.  Hepatitis, other liver disease?                                                YES   NO    48. Arthritis,  rheumatism?

           YES    NO    38.   Stomach  problems,  ulcers?                                                  YES   NO    49. Kidney,  bladder disease?

           YES   NO      39.Allergies to: latex, food,  medications?_________                 YES   NO    50.Thyroid,  adrenal disease?

           YES    NO    40. Family history of diabetes, heart problems, tumors ?               YES   NO    51. Diabetes?

         IV. Do You Have Or Have You Had:                                                                   V.  Are You Taking:

         YES   NO    52.  Tumors, cancer?                                                                           YES    NO   62.Recreational drugs? (Addiction)

          YES    NO   53. Radiation treatments?                                                                  YES     NO     63.  Tobacco in any  form?   

          YES   NO     54. Quemotherapy                                                                            YES      NO    64. Alcohol?

           YES   NO      55.  Prosthetic heart valve?                                                            YES   NO      65.  Drug, medicines, (including Aspirin,Phen-Phen) ?

         YES    NO    56.   Artificial joint?                                                                              Please list______________________________

         YES  NO       57.  Contact   lenses?                                                                        YES    NO   66. Are you taking any Phen-fen, Bisphosphates (Fosamax,

         YES  NO       58. Blood transfusions?                                                                                              Actonel, Bonivia..)?

          YES   NO    59. Surgeries?                                                                                    VI.  Women Only:

          YES   NO       Pacemakers?                                                                              YES    NO    67.   Are you or could you be pregnant or nursing?

           YES    NO    Psichiatric Care?                                                                          YES    NO     68.   Taking birth control pills ?

                                 VII. All Patients:

    Yes     No           68.  Do you  have  had any other diseases or medical problems  NOT listed on this form?

            Please explain__________________________________________________________________________

         To the  best of my knowledge,  I  have answered every  question completely and accurately.  I  will inform 

         Dr. Ingrid Mack  of any change in my health  and or  medication.

          Date____/____/_____ Patient’s Signature_________________________Doctor_______________________