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Medical History
Form

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MM slash DD slash YYYY
Indicate which of the following conditions apply to you presently or in the past.
hospitalization for illness or injury(Required)
allergic/adverse reaction to aspirin(Required)
allergic/adverse reaction to antibiotics(Required)
allergic/adverse reaction to codeine(Required)
allergic/adverse reaction to local anesthetics, etc.(Required)
allergic/adverse reaction to fluoride(Required)
allergic/adverse reaction to metals (gold, etc.)(Required)
allergic/adverse reaction to latex(Required)
allergic/adverse reaction to foods(Required)
allergic/adverse reaction to other medications(Required)
advised against taking any medication(Required)
heart problems (angina, heart attack, rhythm, etc.)(Required)
heart murmur or mitral valve prolapse(Required)
rheumatic or scarlet fever(Required)
artificial heart valve or pacemaker(Required)
artificial joints(Required)
advised to take antibiotics before dental visit(Required)
high blood pressure(Required)
low blood pressure(Required)
high cholesterol(Required)
stroke(Required)
swelling of ankles, feet, or hands(Required)
anemia or other blood disorder(Required)
prolonged bleeding due to slight cut(Required)
asthma(Required)
bronchitis(Required)
tuberculosis(Required)
shortness of breath on exertion(Required)
sinus problems(Required)
kidney disease(Required)
liver disease/jaundice(Required)
hepatitis(Required)
thyroid or parathyroid disease(Required)
hormone deficiency, glandular disorders(Required)
diabetes (personal or family history)(Required)
stomach or duodenal ulcer(Required)
digestive disorders(Required)
special diet presently(Required)
recent weight, appetite or energy level change(Required)
arthritis/rheumatism(Required)
glaucoma(Required)
eye glasses/ contact lenses(Required)
earaches/ear/throat infections frequently(Required)
hearing difficulties(Required)
epilepsy or seizures(Required)
fainting or dizzy spells(Required)
headaches, severe, frequent(Required)
head/neck injuries(Required)
HIV/AIDS(Required)
viral infections, cold sores (herpes)
venereal disease
any lumps or swelling in the mouth(Required)
hives, skin rash, hay fever(Required)
cancer, leukemia, lymphoma(Required)
tumour, abnormal growth(Required)
radiation or chemotherapy(Required)
organ transplant, medical implant(Required)
emotional problems(Required)
psychiatric treatment(Required)
antidepressant medication(Required)
alcohol/drug dependency(Required)
eating disorders(Required)
malignant hyperthermia(Required)
steroid therapy(Required)
diet pill therapy(Required)
presently or in the last year treated for any illness(Required)
any change in your general health in the last year(Required)
a heavy smoker (use chewing tobacco)(Required)
FEMALE – taking birth control pills
FEMALE – pregnant (or suspect you are)
FEMALE – breast feeding
MALE – prostate disorders
CHILD – recent measles, mumps, chicken pox
CHILD – recent strep throat, tonsillitis
Do you currently have, or have had in the past, any disease, condition or problem not listed above?(Required)
Is there anything else about your health we should be made aware of?(Required)
Do you wish to speak to the Doctor privately about any problem or medical condition?(Required)
I, the undersigned, certify that I have provided an accurate and complete personal medical 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 history. Should there be any change in my health status in the future, I will advise this dental office. I authorize the dentist to perform diagnostic procedures that may be required to determine necessary treatment. I understand that information provided from or to my medical doctor(s) or another health care provider may be necessary, and I consent to the release of this information.
I have read and agree to the above release:(Required)
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Medical History Form
New Patient Form

What Our Patients Say

5/5

I’ve been going to Westboro family dentistry for the past few years as well as my son and husband. My son was very nervous for his first dental visit. Dr. Vidal and the hygienist made him feel more comfortable by explaining everything that was going on before hand. I highly recommend this office and will continue going back for years to come

5/5

Had a root canal done with Dr. Vidal and honestly, it was such a smooth experience. I was pretty nervous going in, but Dr. Vidal was super calm and explained everything in a way that really put me at ease. The whole procedure was way easier than I expected - pretty much pain free. Everyone at the office was friendly and professional, and I felt really well taken care of.

5/5

This was by far the best experience I’ve had at a dental office in a while. Dr Vidal was so attentive and was extremely thorough in explaining all the treatment I needed. Would recommend to anyone who wants a dentist that doesn’t oversell treatment and takes time with you to answer any questions you have.

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