WELCOME TO MARKHAM HERITAGE HEALTH CLINIC - DENTISTRY
Title: Dr. Mr. Mrs. Ms. Miss. Other_________________________________
Name___________________________________________________________________
Address:________________________________________________________________
City:______________________________________ Postal Code___________________
Home Tel# _____________________ Bus# _____________ cell# _________________
e-mail address: _________________________
Employer _______________________________ May we call you at work? __________
Occupation ________________________________________
Date of Birth: _________ Sex: M / F Marital Status:__________
Name of Spouse/Partner: __________________________________________
How did you hear about our office? __________________________________________
Insurance Information
Name of Insured: ___________________ Relationship to patient:___________________
Insurance Company: _________________________ Birth Date of insured__________
Name of Employer:_______________Group # ___________ID# _________________
Do you have any additional insurance? Yes
No If yes, complete the following:
Name of Insured: ___________________ Relationship to patient:___________________
Insurance Company: _________________________ Birth Date of insured____________
Name of Employer:________________________________________________________
Group # _________________________ ID# ___________________________________
Can we send your insurance electronically?
Yes
No
I authorize release;to my dental benefits plan administrator and the CDA, information contained in
claims submitted electronically. I also authorize the communication of information related to the
coverage of services described to the named dentist.
If yes, please sign here for the release of information:___________________________
Incase of emergency, whom may we contact? ______________ Phone: ______________
Who is responsible for this account? __________________________________________
Medical Questionnaire
Circle One
Are you presently under the care of a physician?
Yes
No
If so, specify___________________________________________
Are you taking any medicines (antibiotics, birth control, painkillers etc)
If so, specify_____________________________________
Have you ever been hospitalized? ____________________________________
If so, when and how long? ____________________________________
Do you have drug allergies?
If so, specify ______________________________________________
Have you ever had an unusual reaction to any drugs or medications?
If so, specify ______________________________________________
Do you have any other allergies (food, latex, metal, hayfever) ?
If so, specify ______________________________________________
Have you ever taken cortisone or steroids?
If so, specify ______________________________________________
Do you smoke?
Yes
No
How many per day? ___________
Do you have an alcohol/drug dependency?
Have you had radiation treatment or chemotherapy?
If so, explain ___________________________________________________
Women:
Are you pregnant?
Are you nursing?
Yes
Yes
No
No
What month? _____
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
No
Do you have or have you ever had any of the following? (Please circle all that apply)
Anemia
Diabetes
Arthritis
Artificial Heart Valve
Artificial joints/implants
Asthma
Blood disorders
Cancer
Eating Disorders
Epilepsy/seizures
Head/Neck injuries
Heart Murmur
Heart trouble
(Specify)
Hepatitis A, B, C/
Jaundice
Herpes type I/type II
High/Low blood pressure
HIV virus/AIDS
Kidney disease
Rheumatic fever
Stomach/intestinal trouble
Strokes
Thyroid disease
Tuberculosis
Other:
Do you wish to speak to the dentist privately about any matter?
Yes
No
Yes
No
Yes
No
Yes
No
Are there any growths or sore spots in you mouth?
Yes
No
Do your gums bleed when brushing, eating, or do you have pain in your gums?
Yes
No
Does food catch between your teeth?
Are any of your teeth sensitive to heat, cold, sweets or pressure?
Do you use dental floss, proxabrush, stimudents?
How often do you brush your teeth? ___________ When?_____________
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
Do you clench or grind your teeth while awake or asleep?
Yes
Do you have frequent headaches?
Yes
Do you drink coffee, tea, cola regularly? Yes No How much a day? ______
Do you have any emotional concerns about dental treatment?
Yes
Have you ever had an upsetting experience in a dental office, any complications? Yes
Do you have any questions or concerns about dental treatment?
Yes
If yes, please specify _________________________________________
Are you unhappy with the appearance of your teeth?
Yes
What would you like to see changed? ______________________________
What are your long term goals for your teeth, mouth, and smile? _________
What qualities do you look for in a dentist?_____________________________
What are your expectations of our office?______________________________
No
No
Dental Information
Is there any dental problem you would like treated immediately?
If so, specify_____________________________________________
Have you been seeing a dentist regularly?
Date of last visit: _______Last x-rays:_____ last professional cleaning _____
Have you ever been to a dental specialist?
If so, for what were you treated? __________________________________
Do you use a standard or electric toothbrush? ______________________
Do you feel that you have bad breath?
Have you ever experienced any popping/clicking in your jaw joints?
No
No
No
No
Financial Policy:
I assume responsibility of all fees associated with treatment and fully understand that payment is
expected on the date of treatment.
Consent for Treatment:This is to certify that I, the undersigned, consent to the performing of the dental and
oral surgery procedures agreed to be necessary if advisable, including the use of local anesthetic as
indicated and accept the Financial Policy above.
Signature:_______________________________________ Date: __________________
Reviewed by treating dentist: ________________________ Date: __________________