mountroyaldental.com - Existing Patient Medical Update

2043 Mount Forest Drive,
Burlington, Ontario L7P 1H4, Canada
Existing Patient Medical Update
Patient Name*

First NameLast Name
Gender / Title*
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Have you ever been to hospital for any illnesses, operations, trauma/accidents, check-ups/tests?*

YesNo
If Yes, Please Explain*
Have you had a medical examination in the last year?*

YesNo
Are you currently under the care of a physician for any problem?*

YesNo
If Yes, Please Explain*
Are you presently taking any medicine, non-prescription drugs or herbal supplements?*

YesNo
If Yes, What and Why?*
Do you have, or have you ever had, any of the following?*

NONERheumatic FeverKidney DiseaseHeart TroubleDiabetesHeart MurmurLiver Disease (Jaundice, Hepatitis)Joint ReplacementHepatitis CAIDSMental or Nervous DiseaseSinusitisRadiation or X-ray TherapyStrokePacemakerStomach UlcersDrug/Alcohol DependencyOsteoporosis Medications (eg. Fosamax, Actonel)Thyroid DiseaseLung DiseaseHigh Blood PressureAsthmaVenereal DiseaseEpilepsyGastrointestinal DiseaseCancerBlood DisordersAnemiaChest pain, AnginaShortness of BreathSteroid TherapyDialysis
If diabetes is selected, please select the type.*

Diabetes type 1Diabetes type 2
Do you have any conditions or therapies that could affect your immune system? (eg. Leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

YesNo
Do you have any allergies?*

YesNo
If Yes, Please list using the categories*
Have you ever had a peculiar or adverse reaction to any medications?*

YesNo
If Yes, Please Explain*
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (ie: infective endocarditis), a heart condition from birth (ie: congenital heart disease) or a heart transplant?*

YesNo
Do you have a bleeding problem or bleeding disorder?*

YesNo
Have you ever fainted?*

YesNo
If Yes, When?*
Are there any disease or medical problems that run in your family? (eg: diabetes, cancer, heart disease)*

YesNo
If Yes, Please Explain*
Do you smoke or chew tobacco products?*

YesNo
How Much?*
Are you aware of snoring?*

YesNo
Have you been diagnosed with sleep apnea?*

YesNo
Do you use a CPAP machine?*

YesNo
Is there anything that the dentist should know about your general health that has not been mentioned?*

YesNo
If Yes, Please Explain*
To the best of your knowledge, are you in good health?*

YesNo
Women
Are you pregnant / breastfeeding?*

YesNo
Are you on birth control pills?*

YesNo
Office Policy
Please help us maintain the operation of our office on sound principles so that we may assure you and other patients of uninterrupted treatment. Remember that once you have made an appointment, this time is reserved for you. Therefore, 2 business days NOTICE must be given if cancellation is absolutely necessary.

Office policy is that services are paid for at each visit as they are performed. However, in certain circumstances, arrangements for payment may be made by consulting the doctor prior to treatment.

Regarding insurance: All professional services are charged directly to the patient, and patients are personally responsible for the payment of bills on their accounts. We will prepare any necessary forms or reports to help you collect your benefits from your insurance company.
Patient, Parent/Guardian Signature*

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Patient, Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

Existing Patient Medical Update

Women

Office Policy