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*

AdultChild/Adult under Parent/Guardian Care
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / 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*

DayMonthYear
Date
Occupation*
How did you find out about our office?*

FriendFlyerInternetOther
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:*

YesNo
Policy Holder Name
Policy Holder Date of Birth

DayMonthYear
Date
Relationship to patient
Emergency and MD

In case of emergency, we should notify
Name*

First NameLast 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?*

YesNoNot Sure
If you answered yes, please explain below
Do you have unresolved health issues?*

YesNoNot Sure
When was your last medical checkup? *
Has there been any change in your general health in the past year?*

YesNoNot Sure
If you answered yes, please explain below
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

YesNoNot Sure
If you answered yes, please explain below
Have you ever been advised to take premedication before dental treatment?*

YesNoNot Sure
Do you have any allergies to medications, latex/rubber products and any other?*

YesNoNot Sure
If you answered yes, please explain below
Do you have a prosthetic or artificial joint?*

YesNoNot 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?*

YesNoNot Sure
Do you have a bleeding problem or bleeding disorder?*

YesNoNot Sure
Do you take baby aspirin or other blood thinners on a regular basis?*

YesNoNot Sure
Have you ever been hospitalized for any illnesses or operations?*

YesNoNot Sure
Do you have or have you ever had any of the following?

chest pain, anginaheart attackblood pressure problemsshortness of breathrheumatic fevermitral valve prolapseheart surgerycongenital heart defectpacemakerbypass/angioplastytuberculosislung disease, asthmasteroid therapydiabetescancerstrokearthritisstomach ulcersType option 19inflamed bowel diseasethyroid diseaseliver diseaseosteoporosis medicationmalignant hyperthermiasevere headachespsychiatric therapyeating disorderseizures (epilepsy)drug/alcohol dependencysexually transmitted diseaseautoimmune disease
Are there any conditions or diseases not listed above that you have or have had?*

YesNoNot Sure
If so, what?
Are there any diseases or medical problems that run in your family?*

YesNoNot Sure
If you answered yes, please explain below
Do you smoke or chew tobacco products?*

YesNoNot Sure
For women only: Are you breastfeeding or pregnant?

YesNoNot Sure
If pregnant, when is the expected delivery?
Dental History
When was your last dental visit?

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

YesNo
Do any of your teeth ache?*

YesNo
Do have a bad taste or bad breath?*

YesNo
Have you ever had implant surgery?*

YesNo
Do you gums bleed when you brush or floss?*

YesNo
Do you have any pain when you chew?*

YesNo
Have you had any trauma to your jaw or face?*

YesNo
Have you ever had jaw surgery?*

YesNo
Are you nervous during dental treatment?*

YesNo
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*

DayMonthYear
Date
Should be Empty:

New Patient and Medical History Form