Medical Information

same-Day appointments

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226-318-0927

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Home
Our Practice
Dental Care
For Patients
Blog
Gallery
Contact

Leave this field blank

Name:

Gender

Male

Female

Prefer Not To Say

Other

Address (Home):

Email Address:

Name:

Relationship:

Name of Family Doctor:

Phone or Address:

Name of Medical Specialist:

Area of Specialty:

Member ID/certificate numbers

Name of Policy Holder

Insurance Company:

Group/Individual Policy No.:

Name of Policy Holder

Insurance Company:

Group/Individual Policy No.:

Certificate Number/Member ID

1. Are you being treated for any medical condition at the present of have been treated within the past year?

Yes

Not Sure

If so why?

3. Has there been any change in your general health in the past year?

Yes

Not sure

Maybe

Please explain

4. Are you taking any medicationss, non-prescription drugs or herbal supplements of any kind?

Yes

Not sure

Maybe

Please list.

5. Do you have any allergies?

Yes

Please list using the categories below.

a.) Medications

b.) Latex/Rubber products

c.) Other e.g. hay fever,foods...

6. Have you ever had a peculiar or adversee reaction to any medicines or injections?

Yes

Not sure

Maybe

Please explain.

7. Do you have, or have you ever had asthma?

Yes

Not sure

Maybe

8. Do you have, or have you ever had any heart or blood pressure problems?

Yes

Not sure

Maybe

9. Do you have, or have you ever had a heart murmur, mitral valve prolapses or rheumatic fever?

Yes

Not sure

Maybe

10. Do you have a prostheic or artificial joint?

Yes

Not sure

Maybe

11. Have you ever been advised by your doctor to take antibiotics before dental treatment?

Yes

Not sure

Maybe

12. Do you have any conditions or therapies that could affect your immune system e.g. Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy?

Yes

Not sure

Maybe

13. Have you ever had hepatitis, jaundice, or liver disease?

Yes

Not sure

Maybe

14. Do you have bleeding problem or operations?

Yes

Not sure

Maybe

Please explain.

15. Have you ever been hospitalized for any illness or operations?

Yes

Not sure

Maybe

16. Do you have, or have you ever had any of the following?

Chest pain

Angina

Shortness of Breath

Pacemaker

Steroid therapy

Seizures (Epilepsy)

Drug/Alcohol dependency

Heart Attack

Diabetes

Stroke

Tuberculosis

Thyroid Disease

Arthritis

Therapy

Lung Disease

Cancer

Stomach Ulcers

Prosthetic Heart Valve

Kidney Disease

Diet Pill

Please explain.

17. Are there any conditions or disease not listed above that you have or had?

Yes

Not sure

Maybe

What?

18. Do you smoke or ches tobacco products?

Yes

19. Are there any condition or disease not listed above that you have or have had?

Yes

Not sure

Maybe

Are you nervous during dental treatment from a scale to 1-10, 1 being the least and 10 being not nervous?

For women only: Are you breast feeding or pregnant? (optional)

Breast feeding

Pregnant

Oral surgery? (surgery in or about the mouth/jaw joint, or implant surgery inn one or both of your jaw joints?)

Yes

Are there any growths or sore spots in your mouth?

Yes

Do your gums bleed when brushing or eating, or do you suffer from pain or swelling of your gums?

Yes

Have you notices any loose teeth, or have any of your teeth shifted?

Yes

Are any of your teeth sensitive to heat, cold, sweets, or pressure?

Yes

Do you feel that you have bad breath?

Yes

Popping or clicking of jaws?

Yes

Difficulty in opening or closing?

Yes

Same Day Appointments Available

Morning and Evening Appointments

Monday:
11am – 5pm

Tuesday
10am – 5pm

Wednesday
3pm – 8pm

Thursday
11am – 5pm

Friday
12pm – 8pm

Saturday
1 Per Month

Sunday
Closed

same-Day appointments