New Patient Medical History Form

642 Upper James Street, Hamilton, Ontario. L9C 2Z2

Phone: +1-905-574-9617 Fax: +1-905-574-9691

Email: info@thedentalplace.co Website: www.thedentalplace.co
New Patient and Medical History Form

Your cooperation in completing this questionnaire is essential in order to provide you with dental care in a safe and efficient manner. All information is protected by the patient - doctor confidentiality.
Registration Information
The patient is an *

Adult Child/Adult under Parent/Guardian Care
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Alternate/Work Phone Number
Please enter a valid phone number.
Email *
example@example.com
Date of Birth *

Day Month Year
Date
Occupation *
How did you find out about our office? *

Friend Flyer Internet Other
Insurance

Please be advised that dental insurance or benefits is a contract between you, your employer and your insurance provider and any available benefits are determined by your individual policy. Under the Privacy Act, the majority of insurance providers will not provide our office with specific details regarding your coverage. We cannot influence how much of our fees your insurance will cover. Our objective as dental health care providers is to diagnose and recommend treatment according to each patient’s particular needs. We do not know if your insurance will cover the treatment we propose, as this is only outlined in your policy handbook. If you need assistance with the handbook, we can help.
Do you have dental insurance: *

Yes No
Policy Holder Name
Policy Holder Date of Birth

Day Month Year
Date
Relationship to patient
Emergency and MD

In case of emergency, we should notify
Name *

First Name Last Name
Relationship to patient *
Phone Number *
Please enter a valid phone number.
Name of Family Doctor
Phone or Address
Name of Medical Specialist
Area of Speciality
Phone or Address
Medical History
Are you currently being treated for any medical condition or have you been treated within the past year? *

Yes No Not Sure
If you answered yes, please explain below
Do you have unresolved health issues? *

Yes No Not Sure
When was your last medical checkup? *
Has there been any change in your general health in the past year? *

Yes No Not Sure
If you answered yes, please explain below
Are you taking any medications, non-prescription drugs or herbal supplements of any kind? *

Yes No Not Sure
If you answered yes, please explain below
Have you ever been advised to take premedication before dental treatment? *

Yes No Not Sure
Do you have any allergies to medications, latex/rubber products and any other? *

Yes No Not Sure
If you answered yes, please explain below
Do you have a prosthetic or artificial joint? *

Yes No Not Sure
If you answered yes, when was the surgery performed?
Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy? *

Yes No Not Sure
Do you have a bleeding problem or bleeding disorder? *

Yes No Not Sure
Do you take baby aspirin or other blood thinners on a regular basis? *

Yes No Not Sure
Have you ever been hospitalized for any illnesses or operations? *

Yes No Not Sure
Do you have or have you ever had any of the following?

chest pain, angina heart attack blood pressure problems shortness of breath rheumatic fever mitral valve prolapse heart surgery congenital heart defect pacemaker bypass/angioplasty tuberculosis lung disease, asthma steroid therapy diabetes cancer stroke arthritis stomach ulcers Type option 19 inflamed bowel disease thyroid disease liver disease osteoporosis medication malignant hyperthermia severe headaches psychiatric therapy eating disorder seizures (epilepsy) drug/alcohol dependency sexually transmitted disease autoimmune disease
Are there any conditions or diseases not listed above that you have or have had? *

Yes No Not Sure
If so, what?
Are there any diseases or medical problems that run in your family? *

Yes No Not Sure
If you answered yes, please explain below
Do you smoke or chew tobacco products? *

Yes No Not Sure
For women only: Are you breastfeeding or pregnant?

Yes No Not Sure
If pregnant, when is the expected delivery?
Dental History
When was your last dental visit?

Day Month Year
Date
What for?
When did you last have dental x-rays?
Roughly mention month or year
Have you seen a dentist regularly? *

Yes No
Do any of your teeth ache? *

Yes No
Do have a bad taste or bad breath? *

Yes No
Have you ever had implant surgery? *

Yes No
Do you gums bleed when you brush or floss? *

Yes No
Do you have any pain when you chew? *

Yes No
Have you had any trauma to your jaw or face? *

Yes No
Have you ever had jaw surgery? *

Yes No
Are you nervous during dental treatment? *

Yes No
How can we help?
To the best of my knowledge, the above information is correct. I consent to the dental procedures agreed to be necessary or advisable, including the use of local anesthetics and radiographs, as indicated, and I will assume responsibility for fees associated with those procedures.
Patient/Parent/Guardian Signature *

Clear
Date *

Day Month Year
Date
Should be Empty:

New Patient and Medical History Form