Medical History Patient InformationFirst Name *Last Name *Email Address *Date of BirthStreet AddressCityZIP / Postal CodeHome Phone # *Mobile Phone # *Work Phone #EmployerOccupationSpouse’s Name *Phone *Physician’s name and PhoneFormer DentistReferred by:Who should we contact in the event of an emergency?First Name *Last Name *Mobile Phone *Home Phone *DENTAL INSURANCEName of Insurance CompanyDependent NumberGroup/Policy NumberSIN/ID/Employee Number of EmployeeName of SubscriberSubscriber’s Date of BirthYour relationship to SubscriberDo you have two insurance plans?YesNoDependent NumberName of Insurance CompanyGroup/Policy NumberSIN/ID/Employee Number of EmployeeName of SubscriberSubscriber’s Date of BirthYour relationship to SubscriberMEDICAL HISTORYAre you now under the care of a physician? YesNo If so, what is the condition being treated?Have you ever had any serious illness or operation? YesNo If so, what was the illness/operation and where?Have you even been hospitalized? YesNoIf so, what was the problem and when?Are you taking any drug or medicine? YesNoIf so, please list:Are you allergic to or have you reacted adversely to any drug or medicine (e.g. dental freezing, antibiotics, pain killers etc.) YesNoIf so, what happened? Do you have or had any of the following diseases or problems? Rheumatic fever or rheumatic heart diseaseCongenital heart disease Cardiovascular disease (e.g. heart trouble, heart attack, high blood pressure, arteriosclerosis– hardening of the arteries, stroke)Chest pains or shortness of breath Asthma, hay fever, skin rashFainting spells or seizures (e.g. epilepsy)Diabetes Kidney diseaseLiver disease or jaundiceEndocrine disorder (e.g. thyroid disease) Lung or breathing disorders Gastrointestinal disease (e.g. ulcers) Nervous disorderBone, muscle or joint disorders (e.g. osteoporosis, arthritis) Cancer Heart murmurRadiotherapyProsthetic joints or valvesHepatitis HIVHave you ever had abnormal bleeding associated with previous extractions, surgery or trauma?YesNoDo you bruise easily?YesNoDo you have any blood disorder?YesNoDo you smoke or use tobacco products? YesNoIf so, how frequently and for how long?Women: Are you pregnant?YesNoDo you have any disease or problem not listed here you think I should know about? If so, please explain:DENTAL HISTORYHow often do you brush and floss?Which type of brush do you use? ManualElectricAre you presently in any dental pain?YesNoDo your gums bleed?YesNoDo you have difficulty chewing your food?YesNoDo you awaken with pain in your teeth or jaw?YesNoDo you clench or grind your teeth during the day or night? YesNoIf so, do you wear a night guard?YesNoAre you aware of jaw clicking or popping while eating or yawning?YesNoDo you have frequent headaches or facial pain?YesNoDo you ever get food stuck between your teeth?YesNoDo you have an unpleasant taste or odour in your mouth?YesNoIn past years have you been to a dentist on a regular basis? YesNoHow often?Do you have growths or swelling in your mouth?YesNo If yes, for how long?Have you had your wisdom teeth removed?YesNoHave you had orthodontic treatment (braces)?YesNoHave you even been treated for periodontal disease?YesNoIs any part of your mouth sensitive to temperature, pressure, or sweets?YesNoAre you anxious or nervous about dental treatment?YesNoAre you satisfied with your teeth, functionally and esthetically? YesNoIf not, what would you like to improve?Please provide any other information that you feel is relevant:All information you provide is strictly confidential. Please note that insurance companies will NOT notify us of any changes to your existing insurance plan. It is your responsibility to provide us with all up to date details of your insurance policy and coverage. Your appointment time will be reserved especially for you. If you are unable to keep your appointment, please notify us at least 48 hours in advance to avoid a cancellation fee.This is to certify that I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetic and/or relative analgesia as indicated, and I will assume responsibility for fees associated with these procedures. I certify that the medical information provided is accurate and up to date. Send Message
