Patient Information Form

1. Patient Information
2. Medical History
3. Dental History

Spam protection, skip this field

A parent or guardian will be responsible for decisions on my treatment. (optional)

Yes

First Name

Initial

Last Name

Address

City

Postal Code

Date of Birth

Month
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Year
1920
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2040

Home Tel. (optional)

Cel.

Emergency Contact

Tel.

Family Doctor (optional)

Tel. (optional)

Email Address

Medical History (optional)

This information will remain confidential

Date (optional)

Month
January
February
March
April
May
June
July
August
September
October
November
December

Year
1920
1921
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1. Are you presently under the care of a physician?

Yes

Please explain.

2. Have you ever been hospitalized?

Yes

Explain

3. Are you taking any drugs or medication at this time?

Yes

A) Drug (optional)

Reason (optional)

B) Drug (optional)

Reason (optional)

C) Drug (optional)

Reason (optional)

4. Have you ever had any adverse effect to any of the following?

Antibiotic - Penicillin

Sulfonamide

Other

Aspirin

Barbuturates (sleeping pills)

Condeine

Darvon

Local Anaesthetic

None

Other (optional)

5. Have you ever been warned against using any other medications?

Yes

Which?

6. Have you ever taken prolonged medical or non-medical drugs?

Yes

Which? (optional)

7. Do you suffer from any allergies (hay fever, latex etc.)?

Yes

Which? (optional)

8. Do you bruise easily or have prolonged bleeding?

Yes

9. Do you smoke?

Yes

How much per day? (optional)

10. Have you ever fainted, had shortness of breath or chest pains?

Yes

11. For women (optional)

Are you pregnant? (optional)

Yes

Using birth Control? (optional)

Yes

Reached menopause? (optional)

Yes

12. Do you have or have you ever had any of the following?

AIDS

Anemia

Angina Pectoris

Anorexia Nervosa

Artificial Heart Valve

Arthritis/Rheumatism

Artificial Joints (hips, knees)

Asthma

Blood Disorders

Bronchitis

Bulimia

Cancer

Circulation Problems

Congenital Heart Lesions

Cortisone/Steroid

Diabetes

Drug/Alcohol Dependence

Emphysema

Epilepsy

Glandular Disorders

Glaucoma

Head/Neck Injuries

Heart Disease/Attack

Heart Murmur

Heart Pacemaker/Surgery

Heart Rythm Disorder

Hepatitis A/B/C

Herpes

High/Low Blood Pressure

H.I.V. Positive

Hogdkin Disease

Hyper (Hypo) Glycemia

Hypertension

Jaundice

Kidney Disease

Liver Disease

Leukemia

Lung Disease

Malignant Hypothermia

Mental/Nervous Disorder

Mitral Valve Prolapse

Organ Transplant/Implant

Psychiatric Disorders

Radiation/Chemotherapy

Rheumatic/Scarlet Fever

Sickle Cell Disease

Sinus Trouble

Stomach/Intestinal Problems

Stroke

Thyroid Disease

Tuberculosis

Ulcers

Venerial Disease

Other

None

13. For children (optional)

Have you recently had any of the following (approximate date)? (optional)

Chicken Pox

Strep Throat

Measles

Tonsilitis

Mumps

None

1. What is the reason for today's visit?

Emergency

Examination

Other

2. How frequently do you see a dentist?

3-6 months

Annually

Other

3. When was your last dental visit?

Last X-Ray? (optional)

4. How often do you brush per day?

Floss? (optional)

Use anti-bacterial rinse? (optional)

5. Are your teeth sensitive to:

Cold

Sweets

Heat

Other

None

6. Do your gums bleed when:

Brushing

Flossing

Never

7. Do your gums feel swollen or tender?

Yes

8. Do you have bad breath or a bad taste on your mouth?

Yes

9. Do your jaws crack, pop or grate when you open widely?

Yes

10. Do you grind or clench you teeth?

Yes

11. Do you have food catch between your teeth?

Yes

12. Have you ever had local anaesthetic (freezing)?

Yes

Any complications?

Yes

Specify (optional)

13. Have you ever had any problems with previous dental treatments?

Yes

Specify (optional)

14. Have you ever had any of the following:

Bridgework

Orthodontic (braces)

Crowns or Caps

Periodontal (gums)

Full or Partial Dentures

Root Canal

None

15. Are you satisfied with your teeth?

Yes

Specify (optional)

General Release

I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

Date

Month
January
February
March
April
May
June
July
August
September
October
November
December

Year
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040

EMERGENCY TREATMENT

3296 Keele Street. Toronto, ON M3M 2H7