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, ON N6K 0G2

(519) 473-WEST (9378)

CONTACT US

BOOK AN APPOINTMENT NOW

(519) 473-WEST (9378)

captcha