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3296 Keele Street. Toronto, ON M3M 2H7
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Invisalign
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Wisdom Tooth Extraction
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Night Guards and Sports Guards
Children’s Dentistry
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Patient Information Form
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Patient Information Form
1
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Patient Information
2
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Medical History
3
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Dental History
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A parent or guardian will be responsible for decisions on my treatment.
(optional)
Yes
No
First Name
Initial
Last Name
Address
City
Postal Code
Date of Birth
Month
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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
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1. Are you presently under the care of a physician?
Yes
No
Please explain.
2. Have you ever been hospitalized?
Yes
No
Explain
3. Are you taking any drugs or medication at this time?
Yes
No
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
No
Which?
6. Have you ever taken prolonged medical or non-medical drugs?
Yes
No
Which?
(optional)
7. Do you suffer from any allergies (hay fever, latex etc.)?
Yes
No
Which?
(optional)
8. Do you bruise easily or have prolonged bleeding?
Yes
No
9. Do you smoke?
Yes
No
How much per day?
(optional)
10. Have you ever fainted, had shortness of breath or chest pains?
Yes
No
11. For women
(optional)
Are you pregnant?
(optional)
Yes
No
Using birth Control?
(optional)
Yes
No
Reached menopause?
(optional)
Yes
No
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
No
8. Do you have bad breath or a bad taste on your mouth?
Yes
No
9. Do your jaws crack, pop or grate when you open widely?
Yes
No
10. Do you grind or clench you teeth?
Yes
No
11. Do you have food catch between your teeth?
Yes
No
12. Have you ever had local anaesthetic (freezing)?
Yes
No
Any complications?
Yes
No
Specify
(optional)
13. Have you ever had any problems with previous dental treatments?
Yes
No
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
No
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
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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
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