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New Patient Medical History Old Form

NEW PATIENT FORM

We are pleased to welcome you to our practice, and hope to provide you, your family, relatives and friends with the highest quality of dental care.

In order to render the best professional care it is necessary that we become acquainted with the vital information related to each patient. Of course all information is strictly confidential. We appreciate your cooperation in filling out this form carefully and accurately.

PATIENT INFORMATION

A parent or guardian will be responsible for decisions on my treatment:

Yes

No

Title:

Gender:

First Name:

Last Name:

Preferred Name:

Pronounciation:

Date of Birth:

Preferred Pronouns:

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ADDRESS

Address Line One:

Address Line Two:

City:

Province:

Postal Code

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CONTACT INFORMATION

Home Phone:

Work Phone:

Mobile Phone:

Email Address:

Emergency Contact:

Phone Number:

Family Doctor:

Who may we thank for referring you to our office? (Please put N/A if no referring doctor)

Phone Number

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INSURANCE INFORMATION

Methods of Payment

Cash

Debit

VISA

Mastercard

Insurance

Person Responsible for Payment

Self

Spouse

Parent/Guardian

Othe

Do you have Dental Insurance?*:

Yes

No

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If yes, please fill in the following insurance information. Otherwise, skip this section.

Primary Insurance Information

Policy Holder's Name:

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Insurance Provider

Company Name:

Primary Policy Holder's Employer (or N/A)

Group Number

Certificate Number

Insurance Year End: (usually Dec.31)

Annual Coverage:

% Coverage For:

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Secondary Insurance Information (if applicable)

Policy Holder's Name:

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Insurance Provider

Company Name:

Secondary Policy Holder's Employer:

Group Number:

Certificate Number:

Insurance Year End: (usually Dec. 31)

Annnual Coverage:

% Coverage For:

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MEDICAL HISTORY

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Please select yes or no to the following:

Are you presently being treated by a physician?*

If yes, please specify:

Are you taking any medications, pills, drugs, or medicine?

If yes, please list:

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

If yes, to what?

Do any allergic reactions result in headaches, shortness of breath, chest constriction or nausea?

If yes, to what?

Allergies: Have you ever had a reaction to any of the following?

Penicillin

Sulfonamide

Asprin

Barbiturates (sleeping pills)

Codeine

Darvon

Local Anesthetic (Freezing)

General Anesthetic

No Drug Allergies

Other (please specify below)

New Field:

Have you ever been warned against using any other medications?

If yes, please specify:

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

If yes, please specify:

Do you have any medical implants?

If yes, please specify:

Do you bruise easily or have prolonged bleeding?

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

If yes, please specify:

Do your ankles swell?

Do you experience frequent headaches?

Do you have any other disease condition or problem that your doctor should know about?

If yes, please specify:

Do you smoke?

If yes, how many per day?

Women, are you currently pregnant?

If yes, when you are due?

Are you using birth control?

Do you have any of the following:

Aids

Anemia

Angina pectoris

Artificial Heart Valve

Arthiritis/rheumatism

Artificial joints (hips, knees)

Asthma

Blood Disorders

Cancer

Congenital Heart Lesions

Cortisone/steroid

Diabetes

Drug/alcohol dependence

Emphysema

Epilepsy

Heart Disease/Attack

Heart Murmur

Heart Pacemaker/surgery

Heart Rhythm Disorder

Hepatitis A/B/C

High/Low Blood Pressure

HIV Positive

Hyper (Hypo) Glycemia

Hypertension

Kidney Disease

Liver Disease

Lung Disease

Mitral Valve Prolapse

Organ Transplant/Implant

Radiation/Chemotherapy

Rheumatic/Scarlet Fever

Sickle Cell Disease

Sinus Trouble

Stomach/Intestinal Problems

Stroke

Thyroid Disease

Tuberculosis

Ulcers

None of the above

Other

Other:

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

Chicken Pox

Measles

Mumps

Strep Throat

Tonsillitis

None

Is there anything else we should know about your health?

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DENTAL HISTORY

What is the reason for this visit?

Emergency

Examination

Cleaning

Other

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How frequently do you see your dentist?

Every 3-6 months

Annually

Other

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What is the Primary reason for your visit?

Date of your last dental visit?

Date of your last X-Ray?

How often do you brush per day?

How often do you floss per day?

Do you take any pre-medications for dental treatment?

If yes, please specify:

Are your teeth sensitive?

If yes, please specify:

Have you had any past Injury, x-ray therapy, or surgery to your face or jaw?

If yes, please specify:

Does your Jaw pop when opened widely?

If yes, please specify:

Does your mouth hurt when clenched?

If yes, please specify:

Do you experience any pain in your jaw joins or do you suffer from migraines?

If yes, please specify:

Have you had:

Braces

Oral surgery

Gum treatment

Root canal

Have you ever experienced growths or sore spots in your mouth, if so where?

If yes, please specify:

Are you satisfied with the overall appearance of your teeth?

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General Release:

General Release:

I 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 I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as required by this dental office. I authorize this dental office 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 dependants. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

Patient Name:

Today's Date:

Patient Initials:

Thank you for contacting us.
We will get back to you as soon as possible.

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Danforth Neighbourhood Dental Centre

BOOK APPOINTMENT (416) 466-8003

Hours & Address

Mon-Thurs: 8:00 am to 8:00 pm

Friday: 8:00 am to 6:00 pm

Saturday: 8:00 am to 3:00 pm

643 Danforth Ave,

Toronto, ON M4K 1R2

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