Adult Med HX Form

Welcome to our office. The following information will enable us to provide you an accurate evaluation of your orthodontic problem during your initial examination in our office. This information, which is important for our records and your health, is confidential.

About You

Patient Name*

First NameLast Name

Date of Birth*

Date

Age*

Sex*

MaleFemaleOther

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Family Dentist*

Family Physician*

Employed By

Occupation

Person Financially Responsible for the Account*

SelfSpouseParentOther

Please list immediate family members seen in our office

Medical History

General Health

ExcellentGoodFairPoor

Presently under medical care for

Medication currently being taken (drug and dose)

Allergies (latex, metals, acrylic, medications)

Birth defects or hereditary problems

Are you pregnant or suspect you may be?*

YesNoN/A

What is the expected delivery date?

Date

Have you been advised to take antibiotics before a dental appointment?*

YesNo

Have you ever taken bisphosphonates, including Fosamax, Didronel, Boniva, Aredia, Actonel, Skelid or Zometa?*

YesNo

Please check all that apply to you*

Smile Esthetics

Are you unhappy with the appearance of your teeth and smile?*

YesNo

When being photographed, do you smile with your lips closed?*

YesNo

Have you developed any habits to mask your smile?*

YesNo

Does your smile make you feel less confident?*

YesNo

Is there anything about your smile or teeth that you don’t like, would like to change, or would like us to know about?

Dental History

Does your bite feel uncomfortable or unusual?*

YesNo

If yes, please describe

Has your bite changed recently?*

YesNo

If yes, please describe

Do any of your teeth hurt?*

YesNo

If yes, which teeth

Upper rightUpper leftLower rightLower left

Do your gums bleed when brushing or eating, or, do you suffer from pain or swelling of your gums?*

YesNo

Have you ever had treatment for gum disease?*

YesNo

If yes, please describe

Have there been any injuries to your mouth or teeth?*

YesNo

If yes, please describe

Have you ever had any injury in the head and neck area?*

YesNo

If yes, please describe

Do you clench or grind your teeth?*

YesNo

If yes, when do you grind your teeth

While sleepingUnder stressOther

Has your Dentist ever recommended a night guard?*

YesNo

Do you hear clicking, popping or grating sounds in your jaw joints?*

YesNo

If yes, please describe

Have you ever experienced pain in your jaw joints?*

YesNo

If yes, where is the pain

Right sideLeft side

How long have you had this pain?

Do your jaw muscles ever feel tired?*

YesNo

If yes, when?

Have you ever experienced difficulty in opening or closing your jaws?*

YesNo

Have your jaws ever “locked” open or closed?*

YesNo

Do you smoke?*

YesNo

If yes, for how long?

Do you use e-cigarettes, vape or use a Juul?*

YesNo

Do you experience “dry mouth”?*

YesNo

Have you ever had any previous orthodontic treatment (braces, Invisalign)?*

YesNo

If yes, when?

Are you being followed up by any other Dental Specialist?*

YesNo

If yes, who is the Doctor?

Whom may we thank for referring you to our office?*

Airway/Breathing Questionnaire

While sleeping, do you... (Select all that apply)*

Have you ever.... (Select all that apply)*

Stopped breathing during the nightFound it hard to wake up in the morningFelt sleepy during the dayBeen requested to have a sleep studyNone of the above

Do you... (Select all that apply)*

Tend to breathe through the mouth during the dayExperience chronically dry, chapped lipsHave a dry mouth on waking up in the morningWake up feeling like you haven’t sleptHave a problem with sleepiness during the dayFind it hard to wake up in the morningWake up with headaches in the morningNone of the above

I authorize Wilk & Wilk Orthodontics to use the email address provided above for the purposes of maintaining correspondence concerning treatment, account balances, office events, educational information relating to orthodontics, and appointment reminders.

Signature*

Date*

Date

We respect your privacy. We protect your information.

PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

In an effort to respond to the privacy concerns of Canadians, the federal government enacted the Personal Information Protection and Electronic Documents Act (PIPEDA). Effective January 1, 2004, PIPEDA establishes principles for the collection, use and disclosure of personal information in Canada. Wilk & Wilk Orthodontics supports PIPEDA and the provincial privacy laws. We understand the importance of protecting your personal information and are committed to collecting, using and disclosing your personal information responsibly. As a result, Wilk & Wilk Orthodontics has implemented a Privacy Code, which may be reviewed at any time, and a Privacy Information Officer: Dr. Brian E. Wilk.

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us and are all trained in the appropriate uses and protection of your information.

If you have any questions about how your privacy is protected in our office, please feel free to ask.

How Our Office Collects, Uses and Discloses Patients’ Personal Information

Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information.

This office will collect, use and disclose information about you for the following purposes:

• to deliver safe, efficient and high quality patient care
• to assess your health needs and risks
• to advise you of treatment options
• to enable us to contact you and maintain communication with you
• to offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally
• to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists
• to allow us to efficiently follow-up for treatment, care and billing
• for teaching and demonstrating purposes on an anonymous basis
• to complete and submit dental claims for third party adjudication and payment
• to comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated
Health Professions Act
• to comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients’ charts and records to the College in a timely
fashion for regulatory and monitoring purposes
• to permit potential purchasers, practice brokers or advisors to evaluate the dental practice
• to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability
• to prepare materials for the Health Professions Appeal and Review Board (HPARB)
• to invoice for goods and services, process credit card payments and to collect unpaid accounts
• to assist this office to comply with all regulatory requirements
• to comply generally with the law

Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defence of a legal issue.

You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.

Patient Consent

I have reviewed the above information that explains how Wilk & Wilk Orthodontics will use my personal information, and the steps your office is taking to protect my information.

I know that your office has a Privacy Code that I can ask to see at any time, as well as a Privacy Information Officer.

I agree that Wilk & Wilk Orthodontics can collect, use and disclose my personal information as set out above in the information about the office’s privacy policies. I am also aware that if a new purpose arises for the use and/or disclosure of my personal information, your office will seek my approval in advance.

Name*

First NameLast Name

Date*

Date

Signature*