Last Name
First Name
Middle Name Initial
Date Of Birth
Address
APT#
City
Gender MaleFemale
Province
Postal Code
Home Telephone
Mobile Number
Occupation
Business Telephone
Email Address
Physician Name
Physician Address
Physician Phone Number
Dentist Name
Dentist Address
Dentist Phone Number
In Case Of Emergencey Notify:
Name
Relationship
Phone Number
Primary Insurance Company
Policy Holder
Policy Number
Certificate Number
Secondary Insurance Company
Your medical and dental health histories are essential for the determination and course of your treatment in our office. It is important that you complete this questionnaire accurately as it will become part of your office record. Be assured that it will be held in strict confidence.
A. Please check if you have any of the following: (if yes to any of the following, please explain in space provided in section “B”)
AIDS/HIV PositiveAnxietyArthritis(osteo/Rheumatoid)Artificial heart valvesArtificial jointsAsthmaBack ProblemsBlood diseaseCancer ChemotherapyCirculation problemsCortisone treatmentsCough, persistentDiabetesDementia/Alzheimer’sEpilepsyFacial plastic surgeryFaintingFood allergiesGlaucoma
Headaches, frequentHeadaches,migrainesHearing impairmentHeart murmurHeart problems Describe HemophiliaHerpesHepatitis A B CHigh blood pressureJaw PainKidney diseaseLiver diseaseMitral valve prolapsedNervous problemsNeurological problemsPacemakerPsychiatric care
RadiationRespiratory/lung diseaseRheumatic feverSeizure disordersShinglesShortness of breathSkin rashSleep apneaStrokeSurgical implantsSwelling, feet anklesThyroid problemsTobacco use/smoking How much How long TuberculosisUlcers/ColitisOther auto-immune diseases
Known Allergies:
Local anestheticAspirinPenicillin
SulfaIodineLatex
CodeineTetracyclineOther
B. ADDITIONAL MEDICAL INFORMATION:
C. List any medications/vitamins/supplements you are currently taking, including aspirin.
Female patients only
Are you pregnant? If yes, when is due date?
Are you taking birth control pills?
Are you taking hormone replacement?
Are you nursing/breastfeeding
PLEASE CHECK IF YOU HAVE ANY PROBLEMS WITH THE FOLLOWING BELOW: INDICATE WHERE AND HOW LONG
Bad breathBleeding, sensitive gumsBroken fillingsClicking or popping jaw: right or leftFood trapped between teethGrinding or clenching teethGum recession
Loose teethPeriodontal treatmentSensitivity to Cold or HotSensitivity to sweetsSensitivity to biting/chewingSores in mouthStaining
Have you ever been advised to take antibiotics before dental treatment? YesNo
Have you had prolonged bleeding following any medical or dental treatment in the past? YesNo
Are there any growths or sores spots in your mouth? YesNo
Have you ever been diagnosed with periodontal disease? (Gum disease, Pyorrhea) YesNo
Have you ever had dry or burning mouth? YesNo
When was your last Dental Care visit?
What was done?
When was your last dental cleaning?
Have you ever had an allergic reaction to “freezing”? (Local Anaesthetic) If yes, describe:
Is any part of your mouth sore due to clenching or grinding of your teeth YesNo
Have you had any difficult extractions in the past? YesNo
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 or hygienist 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 (x-rays) or other diagnostic measures appropriate for a thorough evaluation as well as the release of all pertinent information to my dental history (including X-rays) to any dentist or physician involved in my treatment and to my dental insurance company, where applicable.
Doctor Name
Introducing
Patient Phone
Referring Dr.
Referring Dr. Address
Referring Dr. Phone
Referring Doctors Clinic Email
Date
Nature Of Referral
Do you have an implant system preference?
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