8-1020 Ottawa St North, Kitchener, ON. N2A-3Z3, P(519)748-2313, Fax(519)896-2837
PATIENT INFORMATION
NAME -FIRST
TITLE (Mr/Mrs/Ms)
LAST
PREFERRED NAME
GENDER(Female/Male)
Family Status
BIRTHDATE
(Circle one)
MARRIED SINGLE
CHILD OTHER
PHONE (Home)
PHONE (Work, include ext.)
MOBILE
ADDRESS (Apt no, Street No, Street name, PO. Box
CITY
PROVINCE
POSTAL CODE
SPOUSE OR RESPONSIBLE PARTY INFORMATION
The following is for: Patients spouse ___ The person responsible for payment ___ Neither ___
NAME -FIRST
TITLE (Mr/Mrs/Ms)
LAST
PREFERRED NAME
GENDER(Female/Male)
Family Status
BIRTHDATE
(Circle one)
MARRIED SINGLE
CHILD OTHER
PHONE (Home)
PHONE (Work, include ext.)
MOBILE
ADDRESS (Apt no, Street No, Street name, PO. Box
CITY
PROVINCE
POSTAL CODE
8-1020 Ottawa St North, Kitchener, ON. N2A-3Z3, P(519)748-2313, Fax(519)896-2837
INSURANCE INFORMATION
Primary Dental
NAME OF INSURED- LAST
FIRST
MI
PATIENT RELATIONSHIP TO INSURED (CIRCLE ONE)
SELF
SPOUSE
CHILD
OTHER
INSURANCE PLAN NAME
GROUP #
ID #
Secondary Dental
NAME OF INSURED- LAST
FIRST
MI
PATIENT RELATIONSHIP TO INSURED (CIRCLE ONE)
SELF
SPOUSE
CHILD
OTHER
INSURANCE PLAN NAME
GROUP #
ID #
Who can we thank for referring you to our office?
1 When was your last medical check up?
2 Within the last year have you been diagnosed or treated for any medical condition? If so why?
3 Has there been any change in your general health in the past year? If yes please explain
4 Please list medications, non- prescription drugs or herbal supplements of any kind that you are
taking.
5 Do you have any allergies? eg. medications, laytex, hayfever, foods?
8-1020 Ottawa St North, Kitchener, ON. N2A-3Z3, P(519)748-2313, Fax(519)896-2837
6 Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes explain.
7 Do you have or have you ever had asthma?
O
Yes
O No
8 Do you have or have you had blood pressure problems?
O
Yes
O No
High Blood Pressure ___
Low Blood Pressure ___
9 Do you have or have you had a heart murmur, mitral valve prolapse or rheumatic fever?
O
Yes
O No
10 Do you have a prosthetic or artificial joint?
O
Yes
O No
11 Have you ever been advised by your Doctor to take antibiotics before dental treatment?
O
Yes
O No
12 Do you have any conditions/therapies that could affect your immune system?
O
Yes
O No
13 Have you ever had a hepatitis, jaundice or liver disease?
O
Yes
O No
14 Do you have a bleeding problem or bleeding disorder?
O
Yes
O No
15 Have you ever been hospitalized for any illness or operations? If yes, please explain.
16 Do you or have you ever had chest pain, angina?
17 Are there any diseases or medical problems that run in your family?
18 Have you ever had a heart attack or stroke?
8-1020 Ottawa St North, Kitchener, ON. N2A-3Z3, P(519)748-2313, Fax(519)896-2837
19 Do you smoke or chew tobacco?
O
Yes
O No
20 Do you suffer from shortness of breath?
O
Yes
O No
21 Do you have a prosthetic heart valve of pace maker?
O
Yes
O No
22 Do you or have you ever had tuberculosis?
O
Yes
O No
23 Do you or have you ever had Cancer? If so please explain.
24 Are you on or have you ever been on Steroid Therapy or on Diet Pill Therapy?
25 Do you or have you ever had Diabetes?
O
Yes
O No
26 Do you or have you ever had stomach ulcers?
O
Yes
O No
27 Do you or have you ever had arthritis?
O
Yes
O No
28 Do you suffer from or have you ever had seizures(epilepsy)
29 Do you or have you ever had Thyroid or Kidney Disease
30 Do you or have you ever had a dependency on drugs or alcohol
31 Do you have any other medical problems that we have not discussed?
Response Date________________________