MEDICAL HISTORY UPDATE (existing patients only)

Existing Patient Form
The information in this questionnaire is CONFIDENTIAL and enables our office to provide the highest level of care and service possible.
Patient Contact Information
Name*

First NameLast Name
Preferred Name:
Date of Birth*

MonthDayYear
Date
Cell Number:*
Please enter a valid phone number.
Email address*
example@example.com
Dental History
Please share the following dates:
Do you smoke or use chewing tobacco?*

YesNo
If yes, how often?
For how long?
Please check any of the following problems that may apply to you:*

None BelowSensitivity (hot, cold and/or sweet)Grinding or clenching teethTooth pain or discomfort while chewingJaw joint pain (clicking/cracking)Bleeding GumsBad breath or bad taste in your mouthBroken teeth or fillingsSore spots/growthsLoose, tipped or shifting teethOther
Do you have or have you ever had any of the following?*

None BelowDenturesBracesPartial denturesPeriodontal (gum) treatmentsDifficult extractionsOther
Medical History
Please check any of the following that apply to you:*

None BelowAIDSDrug addictionHIV positiveRespiratory problemsAllergies, seasonalEmphysemaHPVRheumatic feverAnemiaExcessive bleedingJaundiceRheumatismArthritisFaintingJaw joint painScarlet feverArtificial heart valveGlaucomaKidney diseaseSeizuresArtificial jointsHeart conditionsLiver diseaseSleep apneaAsthmaHeart lesions, congenitalLow blood pressureStomach problemsBlood diseaseHeart murmurMitral valve prolapsStrokeBruise easilyHeart surgeryNervousness/DepressionThyroid diseaseCancerHepatitis APacemakerTuberculosisChemotherapyHepatitis BPhen fen (1 month+)UlcersDiabetesHepatitis CPregnant currentlyVenereal diseasesDizzinessHigh blood pressureRadiation (head/neckOther
Do you have any of the following allergies?*

None BelowPenicillinLatexSulphaNitrous oxideAspirinLocal anaestheticErythromycinValiumCodeinePercocetOther
Have you ever had a joint replacement?*

YesNo
If yes, when?
Has your physician ever told you to take antibiotics prior to dental procedures?*

YesNo
If so, why?
Have you ever experienced complications following a medical or dental procedure?*

YesNo
If yes, please describe:
Are you currently under a physician’s care?*

YesNo
If yes, what for?
Are you taking any medications?*

YesNo
If yes, please specify:
Family Physician’s Name: *
Phone Number: *
Please enter a valid phone number.
PRIVACY INFORMATION
I certify that I have read, understood and accurately completed the personal, medical, and dental histories to the best of my knowledge and have not knowingly omitted any information. This information has been reviewed with me. If required, I consent to my physician being contacted regarding any specific medical question. I authorize the dentist and his/her auxiliary staff to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided.

Consent for Collection, Use and Disclosure of Personal Information

I agree that Oakville Smiles Family Dentistry has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I have been provided with a copy of the consent form and agree that personal information may be collected, used and disclosed as set out in the Privacy Policy at this dental office and is in accordance with the Personal Health Information Protection Act, 2004.
Date*

MonthDayYear
Date
Patient Signature *

Clear
(Parent/Guardian)
Should be Empty:

Existing Patient Form

Patient Contact Information

Dental History

Medical History

PRIVACY INFORMATION