DE Medical History – Davisville Endodontics

Patient Information

In order to aid in evaluating your dental health thoroughly and completely, please complete the following examination questionnaire. This will become part of your office record and will be held in strict confidence.

Title

First Name

Initial

Last Name

Date of birth

Street Address

Apt

City

Postal Code

Home Phone Number

Cell Phone Number

Occupation

Employer

Business Phone Number

Insurance Information

Primary Insurance Holder Name

Policy Holder DOB

Insurance Company Name

Policy/Group #

ID#

Secondary Policy Holder Name

Policy Holder's DOB

Insurance Company Name

Policy/Group #

ID#

Name of Spouse/Parent

Phone Number

Family Doctor

Doctor's Phone Number

Have you ever had an unfavourable reaction following dental treatment?

Yes

Have you ever had excessive bleeding requiring special treatment?

Yes

Please discuss this with the doctor

Yes

Female patients, are you or could you be pregnant or nursing?

Yes

If pregnant, which month?

List of Allergies

List of Medications & Reason (include non-prescription drugs)

Declaration and Signature

I hereby state that the above medical history is to the best of my knowledge, accurate and complete. If I ever have any change in my health, or if my medicines change, I will inform the doctor at the next appointment without fail. If deemed advisable, I grant permission for my physician to be contacted for details and advice. I further authorize the taking of radiographs or other diagnostic measures appropriate for a thorough evaluation.

Type my name

Draw signature

Full legal name

Date signed