Medical & Dental History (Adult)

Filling this in before your visit means less paperwork in the office and more time with your dentist.

About you

So we can set up your file and reach you about appointments.

Date of birth
Gender

For appointment confirmations and reminders

Best ways to reach you
How did you hear about us?

Work, doctor and emergency contact

Is the patient under 18?

Medical history

Your answers help us treat you safely. Everything here stays confidential.

Are you being treated for a medical condition now, or have you been in the past year?
Has your general health changed in the past year?
Do you take any prescription or non-prescription medications, vitamins or herbal supplements?
Do you have any allergies?
Have you ever had an unusual or bad reaction to a medication or injection, including dental freezing?
Do you have, or have you had, asthma?
Do you have, or have you had, heart or blood pressure problems?
Do you have an artificial heart valve, a heart condition you were born with, or a heart transplant, or have you ever had a heart infection (infective endocarditis)?
Do you have an artificial (replacement) joint?
Do you have a condition or treatment that weakens your immune system (e.g. leukemia, HIV, chemotherapy, radiation)?
Have you ever had hepatitis, jaundice or liver disease?
Do you have a bleeding disorder, or do you take blood thinners?
Have you ever been in hospital for an illness or surgery?
Do you have now, or have you had, any of these?

Check all that apply. Leave blank if none.

Any other condition or illness not listed above?
Do any illnesses run in your family (e.g. diabetes, cancer, heart disease)?
Do you smoke, vape, or use tobacco or cannabis?
Are you pregnant?
Are you breastfeeding?
Are you taking birth control pills?

Dental history

How often do you see a dentist?
How often do you brush?
How often do you floss?
Do any of these cause tooth discomfort?

Check all that apply.

Do you have a dental problem that needs attention right away?
Do your gums bleed when you brush or floss?
Have you noticed any loose teeth?
Do you clench or grind your teeth?
Have you been diagnosed with sleep apnea, or do you snore?
Have you had orthodontic treatment (braces or clear aligners)?
Do you feel nervous about dental treatment?
I would like to learn more about

Dental insurance

We bill your plan directly where we can.

Do you have dental insurance?

No insurance? That is fine. We welcome self-pay patients.

Are you covered by the Canadian Dental Care Plan (CDCP)?

Primary plan

Policy holder date of birth
Do you also have a second (coordinating) plan?

Second plan

Policy holder date of birth

Office policy and agreement

Your appointment time is set aside just for you. If you need to cancel or reschedule, please give us at least 48 hours notice so we can offer the time to another patient. Appointments cancelled with less than 48 hours notice, and missed appointments, are subject to a $50 fee, payable before your next appointment.

Please tick each statement to confirm it is true for you

Sign and submit

Your signature confirms the answers and statements on this form.

Who is signing?
Signature

Signed on

Your answers go straight to our office over an encrypted connection. Questions? Call 226-884-2573.