Medical Dental Questionnaire 1 Patient Information 2 Insurance 3 Dental and Medical History Patient InformationName* First Last Gender*MaleFemaleFamily Status*MarriedSingleChildOtherBirth Date* Previous Visit*Email* Home Phone*Cell PhoneBusiness PhoneBest time to call*Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Occupation*Place of Business*Whom may we thank for referring you to our practice?* Dental Office Yellow Pages Internet Newspaper School Work Other Name of person, office, or other source referring you to our practice:* Primary Insurance InformationOptional, you may skip and proceed to next stepName of Insured First Middle Last Insured's Birth Date ID#Group. #Insured Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Insured Employer NameEmployer Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Patient's replationship to insuredSelfSpouseChildOtherInsurance Plan NameInsurance Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Secondary Insurance InformationName of Insured First Middle Last Insured's Birth Date ID#Group. #Insured Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Insured Employer NameEmployer Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Patient's replationship to insuredSelfSpouseChildOtherInsurance Plan NameInsurance Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code MEDICAL HISTORY:The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why?*YesNoNot sure/MaybeIf so, why?2. When was your last medical checkup?*3. Has there been any change in your general health in the past year?*Yes (please explain)NoNot sure/MaybeIf yes, please explain4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*YesNoNot sure/MaybeIf yes, please list.5. Do you have any allergies?*YesNoNot sure/Maybe5a. Medications5b. Latex / Rubber products5c. Other (e.g. hayfever, foods)6. Have you ever had a peculiar or adverse reaction to any medicines or injections?*YesNoNot sure/MaybeIf yes, please explain7. Do you have or have you ever had asthma?*YesNoNot sure / Maybe8. Do you have any heart conditions?*YesNoNot sure/Maybe9. Do you have or have you ever had any high/low blood pressure problems?*YesNoNot sure/Maybe10. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?*YesNoNotsure/Maybe11. Do you have a prosthetic or artificial joint?*YesNoNot sure/Maybe12. Do you have any conditions or therapies that could affect your immune system, (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*YesNoNot sure/Maybe13. Have you ever had hepatitis, jaundice (other than at birth) or liver disease?*YesNoNot sure/Maybe14. Do you have a bleeding problem or a bleeding disorder?*YesNoNot sure15. Have you ever been hospitalized for any illnesses or operations?*YesNoNot sure/MaybeIf yes, please explain16. Do you have or have you ever had any of the following?*Please check chest pain, angina rheumatic fever lung disease stomach ulcers drug/alcohol heart attack heart murmur tuberculosis arthritis organ transplant stroke pacemaker cancer seizures (epilepsy) osteoporosis shortness of breath steroid therapy kidney disease diabetes thyroid disease None of the above 17. Are there any conditions or diseases not listed above that you have or have had? If so, what?*YesNoNot sure/MaybeIf so, what?18. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)*YesNoNot sure/Maybe19. Do you smoke or chew tobacco products?*YesNoNot sure/MaybeHow many per day?Number of years?FOR WOMEN ONLY1. Are you pregnant?*YesNoNot sure/May beExpected delivery date?2. Are you breastfeeding?*YesNo3. Are you taking birth control medication?*YesNoDENTAL HISTORY1. Last dental visit?*2. What was done at that visit?*3. How frequently do you see your dentist?*4. Have you ever had a full mouth series of X-rays (16 or more X-rays taken at the same time)?*YesNoIf yes, approximately when?5. How would you describe your dental health at present?*GoodFairPoor6. What are your present dental concerns, if any?* Bleeding gums Crooked teeth Cosmetic Loose teeth Bad Breath Food Trapping Toothache Loose dentures Missing teeth/spaces Other please specify7. Are you dissatisfied with the appearance of your teeth?*YesNo8. Have you had any teeth extracted due to accident, decay or gum disease?*YesNoIf yes, please explain9. If yes, have you had any complications after extraction?*YesNo10. Have you been taught PREVENTIVE ORAL HYGIENE?*YesNo11. Are you anxious during dental visit?*YesNoPATIENT CERTIFICATION AND CONSENT*I, the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. I will assume full responsibility for the fees associated with these procedures. I agree to the privacy policies posted in the reception area and consent to the electronic sharing of information with my insurance company for the purposes of processing insurance claims and the determination of benefits. Unless other arrangements are made, payment is due at each office visit. Unpaid accounts may be subject to interest. My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and the dentist. I authorize the dentist to treat me and I assume fully responsibility for the fees. I am aware that 2 business days notice is required to change or cancel an appointment without charge. I agree Signature of patient (parent or guardian if under 18)*Date*Captcha Δ
