Clearwater Family Dental: Medical History Form

1
what's your name?* This field is required.
Mr.
Mr.
Mrs.
Ms.
Miss
Dr.
Prefix
First Name
Last Name
2
nice to meet you {yourfullname}!is there another name you'd like to go by?
Preferred Name
3
what's your date of birth?* This field is required.we know. it's not polite to ask. we won't tell anyone!
Month
Day
Year
4
what's your preferred email address?* This field is required.we like to reach out over email for appointments. we promise: no spam!
ex. superflossboss@clearwater.com
5
what's your cell phone number?* This field is required.we text message appointment reminders & communicate over text. the new age is here!
6
we're digital! do you consent to us contacting you?* This field is required.as mentioned, we contact our amazing patients by text or email for appointment reminders
YESNO
7
what gender do you identify as?* This field is required.we usually need this for insurance applications
Male
Female
Transgendered
Undisclosed
8
what's your marital status?* This field is required.
Minor (under 18)
Single
Married
Domestic Partnership
Separated
Divorced
Widowed
9
where do you call home?* This field is required.we need your address for insurance & billing information
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
what's your health card number?we need this to prescribe certain medications. if you don't have one, skip ahead
ex. 1234-123-123-AB
11
your thoughts about treatment decisions...please choose the phrase that best suits your personality
I love making decisions, and want to be involved.
I'm indifferent to decisions at the dentist.
I'd prefer the dentist make decisions for me.
12
your thoughts about treatment details...please choose the phrase that best suits your personality
I prefer not knowing the minor details.
Some days I want the details, while other days I don't care.
Background information is important to me. I love new subjects.
13
your thoughts about order & structure...please choose the phrase that best suits your personality
Plans limit me. I'm spontaneous and flexible.
I don't care greatly about plans, but I need some structure.
I need clear structure. I'm very planned and organized.
14
your thoughts about attention/status...please choose the phrase that best suits your personality
I don't want to attract a lot of attention.
I only need attention when it's necessary.
I love when other people see me as someone special.
15
your thoughts about dental finances...please choose the phrase that best suits your personality
I only want to do what my dental insurance covers. Not a penny more.
I'm okay spending more than what insurance covers if it's necessary.
I'm not concerned greatly with cost. I just need what's necessary to be done.
16
are you okay having the TV play overhead while in the chair?we know some patients prefer no distractions, while others welcome something to watch!
YESNO
17
do you have any issues that limit chair movement?if you cannot be set back all the way or your neck has limited movement, let us know!
YESNO
18
what type of issues do you have?our goal is the cater our dental office to your needs. Let us know so we can serve you better!
ex. can't be set back; wheelchair-bound; limited neck movement
19
how did you hear about us?* This field is required.we’d love to know how you heard about us!
Google
Doctor
Facebook
Family Member
Flyer
Friend
Google
Instagram
Local Event
Locations/Signs
Mug
Radio
Specialist
Other
20
who told you about us?we'd love to say thank you to the fine individual who referred you!
ex. Our neighbour Mr. Wilson
21
are you responsible for this account?* This field is required.are you in charge of handling the billings/payments for this account?
YESNO
22
who's in charge of this account?
Mr.
Mrs.
Ms.
Miss
Dr.
Prefix
First Name
Last Name
23
we will need the account holders phone number
Area Code
Phone Number
24
do you have dental insurance?* This field is required.we accept all types of dental insurance (ex. Sunlife, Manulife, etc.)
YESNO
25
is your insurance through ODSP, Ontario Works, Health Smiles or the new CDCP program?
YESNO
26
Please check and agree to each statement:we need to make sure you're aware of what's required to qualify for dental coverage!
27
do you have any other types of insurance?insurance other than government-subsidized coverage will need to be provided first
YESNO
28
primary dental insuranceit's helpful to have your insurance card on-hand for this part
your primary insurance dental company (ex. Manulife, Sunlife)
the account subscribers name
date of birth (ex. Jan 1, 1995)
employer
policy plan number
certificate/ID number
29
do you have secondary dental insurance?
YESNO
30
secondary dental insuranceit's helpful to have your insurance card on-hand for this part
your primary insurance dental company (ex. Manulife, Sunlife)
the account subscribers name
date of birth (ex. Jan 1, 1995)
employer
policy plan number
certificate/ID number
31
is anyone else in your family a patient at our office?
YESNO
32
when was the last time you...?* This field is required.best guess is all we need to know!
had any type of dental visit?
had any type of dental cleaning done?
had any type of dental x-rays taken?
33
do you use any tobacco or nicotine products?* This field is required.this includes cigarettes, chewing tobacco, hookah, or vape products.
YESNO
34
do you smoke/consume any marijuana products?* This field is required.this includes using CBD oils and other related products.
YESNO
35
please check any of the following problems you may have:if nothing applies, click NEXT.
sensitivity (hot, cold, and/or sweets)
headaches, ear aches, neck pain
tooth pain or discomfort while chewing
grinding or clenching your teeth
jaw pain or joint pain (clicking/popping, or previously diagnosed TMD)
bleeding teeth or fillings
broken teeth or fillings
loose, tipped, or shifted teeth
bad breath or bad taste in your mouth
sore spots or growths
36
do you have or have you had any of the following:if nothing applies, click NEXT.
dentures
partial dentures
braces/clear aligners
gum disease
difficult tooth extractions
a night-guard/bite splint
37
if you could change your smile, you would....if nothing applies, click NEXT.
make your teeth brighter
repair chipped teeth
make your teeth straighter
replace missing teeth
close spaces/gaps
replace discoloured dental work
replace silver fillings to white ones
have a smile makeover
38
some information about your last dentist:if you'd rather not say, click NEXT.
name of your previous dentist?
why did you leave your last dentist?
39
has anything kept you from having dental treatment?* This field is required.
YESNO
40
what has kept you from dental treatment?
ex. bad experience, finances, fear of mint flavouring
41
please mark any conditions you have or have had in the past:(part one)
AIDS
Allergies (seasonal)
Anemia
Arthritis (Rhem/Osteo)
Artificial heart valve
Artificial joints
Asthma
Blood disease
Bruise easily
Cancer
Chemotherapy
Diabetes
Dizziness
Drug Addiction
42
please mark any conditions you have or have had in the past:(part two)
Emphysema
Excessive bleeding
Fainting
Glaucoma
Heart Conditions
Heart lesions (congenital)
Heart murmur
Heart surgery
Hepatitis A
Hepatitis B
Hepatitis C
High blood pressure
HIV positive
HPV
43
please mark any conditions you have or have had in the past:(part three)
Jaundice
Jaw joint/TMJ pain
Kidney disease
Liver disease
Low blood pressure
Mitral valve prolapse
Anxiety/depression
Pacemaker
Fen-Phen (use +1 month)
Currently pregnant
Radiation treatment
Respiratory problems
Rheumatic fever
Rheumatism
44
please mark any conditions you have or have had in the past:(part four... LAST ONE!)
Scarlet fever
Seizures
Sleep apnea
GERD/acid reflux
Stroke
Thyroid disease
Tuberculosis
Ulcers
Venereal disease
Other
45
women: are you pregnant or think you may be pregnant?click NEXT if this does not apply to you.
YESNO
46
are you nursing/breast-feeding?this information is important when prescribing medications.
YESNO
47
please list any medications you are currently taking:this includes non-prescription drugs, herbals, vitamins, and birth control medications.
ex. aspirin, ventolin inhaler, vitamin e, etc.
48
some information about your pharmacythis optional info will help us send prescriptions directly to the pharmacy to quicken pickup.
your pharmacy's name
your pharmacy's location
49
please list any drug allergies you have:* This field is required.please select "no known drug allergies" if you do not have any drug allergies.
Penicillin
Erythromycin
Codeine
Latex
Aspirin
Sulpha
Local anesthetic
Nitrous oxide
Valium
Percocet
No known drug allergies
Other
50
sign below to verify that all your health information is accurate:* This field is required.(it's okay, the digital signatures never look pretty)
51
Privacy Consent Form* This field is required.
52
Office Cancellation Policy* This field is required.
53
Financial Agreement* This field is required.
54
Patient Certification & Consent* This field is required.
55
I agree to the Patient Certification & Consent terms* This field is required.by signing you agree to all terms & conditions.
Should be Empty: