Appointment for Mobile Dental Care Clinic in Greater Toronto Area

Medical history Form

Medical History Form

Personal Information

Title

First Name

Last Name

Address

Country

Address Line 1

Address Line 2

City

Province

Postal Code

Home Phone

Cell Phone

Work Phone

Age

Date of Birth

Gender

How did you hear about us?

Employment & Insurance

Employer

Occupation

Insurance Company

Policy Number

Certificate Number

Secondary Insurance

Policy Number

Certificate Number

If Other, please explain:

Family Doctor

Family Doctor's Phone Number

Medical Specialist

Medical Specialist's Phone Number

Dentist

Dentist's Phone Number

Emergency Contact

Emergency Contact's Phone Number

Relationship to Patient

Dental History

Date of Last Dental Visit

Date of Last Cleaning

Do you have full or partial dentures?

Yes

Do you have any pain in your teeth or gums?

Yes

Are your teeth sensitive to hot, cold, sweets or pressure?

Yes

Are you interested in having whiter teeth?

Yes

Are you happy with your smile?

Yes

How often do you brush your teeth?

How often do you floss your teeth?

Have you ever had gum surgery?

Yes

Do you have dental implants?

Yes

Medical History

Are you being treated for any medical condition at present or within the past two years? If yes, please explain.

Have you been hospitalized in the past two years? If yes, please explain.

Have you recently, or are presently, taking any prescription or non-prescription drugs including herbal remedies?

Do you have a prosthetic or artificial joint?

Yes

Do you have any allergies to medications? Other allergies (latex or metal)? Please list.

Do you have any other problem not listed above?

Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction? If yes, please explain.

Do you bleed over 5 minutes when cut? Do you bruise easily? If yes, please explain.

Do you experience shortness of breath or chest pain when taking a walk or climbing stairs? If yes, please explain.

Do you have any hearing difficulties? If yes, please explain.

Do you smoke or use any other forms of tobacco? If yes, please explain.

WOMEN: Are you Pregnant?

Yes

Not Applicable

WOMEN: Do you take Birth Control Pills?

Yes

Not Applicable

WOMEN: Do you take a hormone supplement?

Yes

Not Applicable

Do you currently have, or have you had in the past, any disease, condition or problem not listed above?

Yes

If yes, please tell us about it.

Can we send you occasional updates about your dental hygiene to your email address?

Yes

GENERAL RELEASE

By submitting this form, you certify that you have provided an accurate and complete personal and medical – dental history and have not knowingly omitted any information. You have had the opportunity to ask questions and receive any questions regarding your medical – dental history. Should there be any change in either your health status or any other information you have provided, you will advise the dental hygienist. You authorize the provider to perform dental hygiene diagnostic procedures as may be required to determine necessary treatment. You understand that information provided from, or to, your medical doctor or another health provider may be necessary. This office has a privacy policy that protects your personal information. You understand that responsibility for payment of the dental services for yourself and your dependents is yours, and you assume responsibility for fees associated with these services.

I agree.