Full Medical Form

Patient Name*

Date of Birth*

Address*

City*

Province*

Postal*

Home Phone*

Work Phone

Cell Phone

Email*

Preferred Method of Contact*

Home
Work
Cell
SMS
Email

Preferred Confirmation Method*

Home
Work
Cell
SMS
Email

Emergency Contact (name & phone number)*

If you have dental Insurance, please provide the following information:

Primary Insurance

Insurance Company Name

Subscriber name and Date of Birth

Relationship to subscriber

Group number

Certificate number

Secondary Insurance

Insurance Company Name

Subscriber name and Date of Birth

Relationship to subscriber

Group number

Certificate number

Although dental personnel primarily treat the area in and around the mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking could have an important interrelationship with the dentistry you receive. We thank you for your cooperation in answering the following questions.

Doctor’s name and phone number*

Medical specialist’s name and phone number (if applied)

MEDICATION

WHAT FOR?

DOSE

FREQUENCY

Pharmacy name and location

Have you ever been hospitalized or had a major operation?

Yes
No

If yes, please explain

Have you ever had a serious head, neck or jaw injury?

Yes
No

If yes, please explain

Are you on a special diet?

Yes
No

Women: Are you pregnant?

Yes
No

Due Date

Taking Contraceptives?

Yes
No

Are you allergic to any of the following?

Aspirin
Penicillin
Sulfa Drugs
Codeine
Local Anesthetic
Acrylic
Metal
Latex
Other?

Please explain:

Do you have, or have you ever had, any of the following? Check all that apply

Have you ever had any conditions or diseases not listed above?

If this your first time to this office, when was your last dental visit

Are you currently experiencing any dental problems/concerns?

Yes
No

If yes, please explain

DENTAL CARE

How often do you brush your teeth?

Do you use an electric toothbrush?

Yes
No

How often do you floss your teeth?

Other dental tools

Do you feel you have bad breath?

Yes
No

Are there any growths or sore spots in your mouth?

Yes
No

Does food get caught between your teeth?

Yes
No

Are any of your teeth sensitive to heat, cold, sweets or pressure?

Yes
No

Jaw problems

Yes
No

a) Popping/clicking in your jaw joints

Yes
No

b) Pain in your jaws, around your ear, or side of your face

Yes
No

c) Difficulty in opening or closing

Yes
No

d) Pain when teeth are clenched

Yes
No

e) Pain/difficulty in chewing

Yes
No

Are you happy with the appearance of your teeth?

Yes
No

Have you noticed any loose teeth, or have your teeth shifted?

Yes
No

Have you ever had one of the following:

Yes
No

a) Periodontal Treatment (treatment of the gums)

Yes
No

b) Orthodontic Treatment (to straighten or realign teeth)

Yes
No

c) A bite plate or any other appliance

Yes
No

d) Oral surgery (surgery in or about the mouth/jaw joint or implant surgery in one or both of your jaw joints)

Yes
No

Do you clench or grind your teeth while awake or asleep?

Yes
No

Do you bite your cheeks or lips regularly?

Yes
No

Do you breathe through your mouth while awake or asleep?

Yes
No

Do you hold foreign objects in your teeth (pencils, nails, pipes, pins, fingernails)

Yes
No

Do you smoke?

Yes
No

a) If yes, how many cigarettes a day and for how long?

b) If no, have you ever smoked in the past?

Do you vape?

Yes
No

Do you use smokeless tobacco?

Yes
No

Do you smoke a pipe?

Yes
No

Do you use cannabis?

Yes
No

Do you drink coffee or tea?

Yes
No

Do you drink soft drinks?

Yes
No

Do you have a thumb or finger habit?

Yes
No

Do you have tongue thrust?

Yes
No

Do you bite your nails?

Yes
No

Do you use toothpicks/stimulator?

Yes
No

Do you chew gum?

Yes
No

Do you eat candy?

Yes
No

Are you or have you ever been bulimic or anorexic?

Yes
No

Do you snore?

Yes
No

Do you have sleep apnea?

Yes
No

Do you have any concerns about your teeth or your smile?

Have you ever had an upsetting experience in a dental office, or any complications during or following dental treatment?

How did you hear about us?

Cancellation Policy: When you book an appointment with us, we reserve that time specifically with the dentist or hygienist. As such, we require two business days (48 hours) notice in the event an appointment must be changed or cancelled. This allows other patients awaiting treatment to be rescheduled in the slot initially reserved for you. Short notice cancellations (i.e. less than 48 hours’ notice) and no show appointments will be subject to a broken appointment fee, in the amount 40$, will be directly charged to the credit card on file. This fee will be used as a donation to sponsor a child through the CHEO Foundation. Life happens and we understand that sometimes you just can’t make it for a valid reason, in this case your card will not be charged for a first offence if it is for a valid reason. A Tax receipt for your donations will be given in February of the following year.

To the best of my knowledge the above information has been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any medical changes.

Signature of Patient/ Parent/ Guardian*

Name of Parent / Guardian (if applicable)

Date*

Signature of Dental Provider

613-746-6666