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

    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 had any implant surgery 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