Patient Information Form

Gender
MF

Please indicate the best time to contact you for appointments:
Any TimeDays OnlyEvenings OnlyWeekends

Do you have family members or friends that are patients of this office?
NoYes

In case of an emergency, contact:

DENTAL INSURANCE (PRIMARY COVERAGE)

DENTAL INSURANCE (ADDITIONAL COVERAGE)

Medical History

Are you presently under a doctor's care?
YesNo

Are you presently taking any drug or medication, or have you taken any in the last 6 months?
YesNo

Are you presently taking any homeopathic products?
YesNo

Have you ever been hospitalized or have you ever had surgical intervention other than dental?
YesNo

Have you ever been diagnosed or treated for cancer?
YesNo

Have you ever had a heart transplant, heart infection, artificial heart valve or heart condition from birth?
YesNo

Do you smoke or chew tobacco products?
YesNo

Do you have any conditions/therapies that could affect your immune system? (e.g. Leukemia, AIDS, Cherne)
YesNo

Have you ever had and/or been treated for:

Blood Pressure (High/Low)
YesNo

Digestive Problems
YesNo

Diabetes
YesNo

Eye Problems
YesNo

Asthma
YesNo

Frequent Colds or Sinusitis
YesNo

Kidney Disease
YesNo

Prolonged Bleeding
YesNo

Lung Disease
YesNo

Mitral Valve Prolapse
YesNo

Pacemaker
YesNo

Venereal Disease
YesNo

Dizzy Spells or Fainting Spells
YesNo

Epilepsy
YesNo

Nervous Disorders
YesNo

Stomach Ulcers
YesNo

Hay Fever
YesNo

Earaches
YesNo

Skin Disease
YesNo

Frequent Headaches
YesNo

Drug/Alcohol Dependency
YesNo

Osteoporosis
YesNo

Rheumatic / Scarlet Fever
YesNo

Liver Disease (Hepatitis)
YesNo

Arthritis
YesNo

Back Problems
YesNo

Artificial Joints or Implants
YesNo

AIDS / HIV Positive
YesNo

Thyroid Problems
YesNo

Anemia
YesNo

Tuberculosis
YesNo

Leukemia
YesNo

Are you allergic to or have you ever had reactions to

Specific Foods
YesNo

Antibiotics (Penicillin)
YesNo

Iodine
YesNo

Latex (Rubber)
YesNo

Sedatives
YesNo

Sulfa Drugs
YesNo

Aspirin/Codeine
YesNo

Local Anesthetics
YesNo

Metals
YesNo

Flavours (e.g. Mint)
YesNo

Have you ever been told not to donate blood?
YesNo

Have you ever taken drugs for osteoporosis or bone cancer? (Aredia, Actonel, Fosamax, etc.)
YesNo

Women Only:

Are you pregnant or think you are pregnant?
YesNo

Are you presently nursing?
YesNo

Are you presently taking oral contraceptives?
YesNo

DENTAL HISTORY

Last visit:
0-6 Months6-12 Months> 12 Months

Have you been seeing a dentist regularly?
YesNo

Do any of your teeth ache?
YesNo

Have you been seeing a dentist regularly?
YesNo

Do your gums bleed when you brush?
YesNo

Do you have any pain when you chew?
YesNo

Do you feel that you have bad breath?
YesNo

Have you ever experienced any blows to your jaw?
YesNo

Have you ever been advised to take antibiotics before dental appointments?
YesNo

Are you being followed up by a dental specialist?

Are you nervous during dental treatment?
YesNo

INFORMED CONSENT

I, the undersigned, hereby declare that I have read, understood and
answered the above medical-dental questionnaire to the best of my
knowledge. I also hereby promise to inform my dentist of any changes to
my health.

I authorize the setting up of my dental file, its follow-up, as well as my
registration on the recall list(s) of the treating dentist(s ).
I have been informed that my file will be kept in the office at all times and
that only the dentist(s) and his/her (their) auxiliary personnel will have
access to it.

I also have been informed of my right to consult my file, to request that it
be corrected, if necessary, and to remove my name from the recall list.

I acknowledge that I have read the answers to the above questionnaire
and that I have taken the customary measures, as the case may be.

YesNo