Form: Medical Dental History – Adult 2018-12-28T05:25:44+00:00

MEDICAL DENTAL HISTORY

MEDICAL/DENTAL HISTORY FORM – ADULT

     Do you have dental insurance?
    YesNo

    If YES, complete the following

     Primary Insurance

     Secondary Insurance

     Has there been any change in your general health?

    YesNo

     Are you being treated for any medical condition or have you been treated within the past 2 years?

    YesNo

     Are you currently being treated by a physician for a specific condition?

    YesNo

     Are you currently taking any medication?

    YesNo

     Do you bleed or bruise easily?

    YesNo

     Have you ever been hospitalized?

    YesNo

     Have you ever received general anesthesia?

    YesNo

     Have you ever had an adverse reaction to local anesthetic?

    YesNo

     Do you have any allergies to medications?

    YesNo

     Do you have any other allergies?

    YesNo

     Do you currently have any of the following conditions?

    Heart Murmur

    Osteoporosis

    Osteopenia

    Rheumatic Fever

    Asthma

    COPD

    Sleep Apnea

    Hepatitis A/B/C/D

    Thyroid Disease

    Mental Illness

    AIDS/HIV

    Herpes / Cold Sore

    Emotional Problems

    Heart Attack

    Angina

    Glaucoma

    Atherosclerosis

    Stroke

    Kidney Disease

    Liver Disease

    Kidney Disease

    Kidney Disease

    Drug/Alcohol Abuse

    Cancer

    Jaundice

    ADHD

    Epilepsy

    Pacemaker

    Organ Transplant

    Arthritis

    Radiation Therapy

    Steroid Therapy

    Stress

    Diabeter Type 1 / Type 2

    Steroid Therapy

    Surgery to Head and Neck

     Is there anything else the doctor needs to know regarding your medical health?

    YesNo

     Do you smoke?

    YesNoQuit

    TobaccoCigarsChewOthers

     Females ONLY

     Are you or could you be pregnant?

    YesNo

     Are you currently breast-feeding?

    YesNo

     Dental History

     Are you currently experiencing any pain or discomfort?

    YesNo

     Are any of your teeth sensitive to

    ColdHotSweetBiting

     Do you have difficulty chewing food or does food get stuck between your teeth?

    YesNo

     Are you unhappy with the overall appearance of your teeth?

    YesNo

     Have you had braces for straightening your face?

    YesNo

     Have you ever had an injury to your jaw or face?

    YesNo

     Does your jaw ever click or pop or cause pain upon opening or closing?

    YesNo

     Are you nervous during dental treatment?

    YesNo

    PATIENT CERTIFICATION AND CONSENT

    I the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. I will assume full responsibility for the fees associated with these procedures. I agree to the privacy policies posted in the reception area and consent to the electronic sharing of information with my insurance company for the purpose of processing insurance claims and determination of benefits. Unless other arrangements have been made assignment of benefits from your insurance company will be set up. My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and my dentist. I authorize the dentist to treat me and I assume full responsibility for all fees. I am aware that 2 business days notice is required to change or cancel an appointment without charge.

    ___________________________________________________
    SIGNATURE (PARENT OR GUARDIAN IF UNDER 16)

    To be signed at your appointment

    OUR CLINIC

    1295 Riverbend Road Suite 260 London, Ontario

    reception@westfivedental.ca

    CONTACT US

      BOOK AN APPOINTMENT NOW

      (519) 473-WEST (9378)

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