We have taken measures to secure the information submitted by this form and to protect the privacy of your personal information.

Fields/sections marked with * must be completed.

PATIENT PERSONAL INFORMATION
*First Name:
*Last Name:
*Gender:
Male Female
*Date of Birth:
*Health Card #:
Occupation:
PATIENT CONTACT INFORMATION
*Address:
*City:
*Postal Code:
*Phone:
aaa-bbb-cccc
Alternate Phone:
aaa-bbb-cccc
Email:
PATIENT DOCTOR INFORMATION
*Family Dentist:
Family Dentist Phone:
aaa-bbb-cccc
Family Doctor:
Family Doctor Phone:
aaa-bbb-cccc
Medical Specialist:
Area of Specialty:
Medical Specialist Phone:
aaa-bbb-cccc
*Who referred you?
PATIENT PAYMENT INFORMATION
*Who is making payment?
Self  Employer  Other
*Dental insurance?
Yes  No
*Method of Payment:
Cash  Visa  Mastercard  interac
*Government Funded Program?
Yes  No

In Case of emergency, notify:
Name:
Relationship:
Phone:
aaa-bbb-cccc
Who is with you today?
* General Medical History
Has there been any change in your general health over the past year?
Yes No Briefly describe
Are you presently under a physician’s care?
Yes No Last physical examination (approx. date)

The following sections deal with specific health areas and conditions. When you come for your appointment a nurse and doctor will review the form with you and may ask follow up questions. If a section does not apply to you use the None of these conditions/questions apply to me checkbox at the bottom of that section.

* Brain/Spine
Check any conditions that apply to you
General Depression
Bipolar Depression
Anxiety Disorder
Anorexia / Bulemia
Schizophrenia / Schizoaffective disorder
Alzheimer’s
Parkinson’s Disease
Seizure disorder
Multiple Sclerosis
Myasthenia Gravis, Muscular Dystrophy
Have you ever fainted before?
Yes  No
Have you ever had a panic attack?
Yes  No
 
None of these conditions/questions apply to me
* Heart
Check any conditions that apply to you
High Blood Pressure
High cholesterol
Aneurysm
History of Heart Attack
History of angina/chest pain
History of a stroke
History of irregular heart beat
History of heart murmur
Fake heart valve
Heart Failure
Cardiac Pacemaker/defibrillator
Heart defect from birth?
Yes  No
Can you walk up two flights of stairs?
Yes  No
Do you have to sleep with a pillow so that you do not get out of breath?
Yes  No
Do your ankles swell?
Yes  No
 
None of these conditions/questions apply to me
* Lungs
Check any conditions that apply to you
Asthma
COPD (chronic bronchitis/emphysema)
Blood clot in your lungs/veins of legs/arms
Pneumonia
Tuberculosis
Sleep Apnea
Sinus trouble/Sinus disease
Any recent sore throat or phlegm filled cough?
Yes  No
Do you feel chronically tired, even after you sleep?
Yes  No
 
None of these conditions/questions apply to me
* Glands/Hormones
Check any conditions that apply to you
Diabetes
Thyroid or parathyroid irregularities
Adrenal (steroid) gland abnormality
Have you taken steroid pills?
Yes  No
 
None of these conditions/questions apply to me
* Stomach
Check any conditions that apply to you
Crohns Disease or Ulcerative Colitis
Acid Reflux
Ulcers
Hepatitis A/B/C
Jaundice/Liver disease
Alcohol withdrawl
Pancreatitis (h/o of acute/chronic)
Are you having normal bowel movements?
Yes  No
 
None of these conditions/questions apply to me
* Kidneys
Check any conditions that apply to you
Acute kidney disease
Chronic kidney disease
Dialysis treatment
Polycystic kidney disease
Do you take supplements for or have irregular levels of Potassium, Sodium, Calcium, Magnesium
Are you urinating normally?
Yes  No
 
None of these conditions/questions apply to me
* Bleeding
Check any conditions that apply to you
Hemophilia A or B
Thrombotic thrombocytopenic purpura (TTP), Idiopathic thrombocytopenic purpura (ITP)
Von Willebrand Disease
Iron deficiency anemia
Sickle cell anemia
Have you ever had abnormal bleeding after any surgery, extraction or trauma?
Yes  No
Do you bruise easily?
Yes  No
Do you get nosebleeds frequently?
Yes  No
Have you ever had a blood transfusion?
Yes  No
 
None of these conditions/questions apply to me
* Bones and Joints
Check any conditions that apply to you
Osteoarthritis
Rheumatoid Arthritis
Osteoporosis
Artificial joint replacement
Have you ever received an intravenous medication known as bisphosphonate? For example - Zometa (zoledronic acid) or Aridia (pamidronate)?
Yes  No
Are you taking or have you taken the oral medication known as bisphosphonate for osteoporosis or another medical condition? For example - Fosamax (alendronate), Actonal (risedronate) or Boniva (ibandronate sodium)?
Yes  No
Are you taking or have you taken an injection of the medication Prolia (denosumab) for osteoporosis or another medical condition?
Yes  No
 
None of these conditions/questions apply to me

* Other
Check any conditions that apply to you
Syphilis, Gonorrhea, Herpes Simplex virus, human papilloma virus or other sexually transmitted infections
HIV or other immunodeficiency
Cancer/Tumour/Malignancy
Glaucoma
Do you wear contact lenses?
Yes  No
Do you have or have you ever had ANY disease, condition, or problem NOT listed above?
Yes  No
 
None of these conditions/questions apply to me

* Medication List
Please list any type of medication you are presently taking (prescription or non-prescription).
Please specify if you are taking blood thinners:
Medication / Dose / Frequency
 
I do not take any medications
* Allergies/Sensitivities
Check any allergies or sensitvities that apply to you
Local anesthetic (freezing)
General anesthetic (being put to sleep in the hospital)
Antibiotic (like PENICILLIN or AMOXICILLIN)
Codeine/narcotic
Latex
Other
 
I do not have any allergies

* Past Surgical History/Hospitalizations
Have you ever had a surgery before?
Yes  No Did you have any bleeding complications or complications related to the anesthesia/sedation?
Have you been to the hospital for anything other than surgery?
Yes  No
 
I have not had surgery/hospitalizations in the past
* Family History
Is there a history of any bleeding disorders?
Yes  No
Is there any history or problems or complications related to going to sleep in the hospital under anesthesia?
Yes  No
Do you have a family history of heart disease?
Yes  No
 
None of these conditions/questions apply to me
* Social History
Do you smoke cigarettes or cigars?
Yes  No How many per day?

How many years?
Do you drink alcohol?
Yes  No How many drinks per day on average?
Do you use any recreational drugs?
Yes  No How many times per week on average?
 
None of these conditions/questions apply to me

* For Women
Is there any chance you could be pregnant?
Yes  No
Are you breastfeeding?
Yes  No
Are you taking oral contraceptives?
Yes  No
 
None of these conditions/questions apply to me
* Considering Sedation for Surgery?
Are you considering sedation/relaxation medication during surgery?
Yes  No
Do you snore loudly?
(loud enough to be heard through closed doors)
Yes  No  Not known
Do you often feel tired, fatigued, or sleepy
during the daytime?
Yes  No
Has anyone observed
you stop breathing
during your sleep?
Yes  No  Not known
Do you have or are
you being treated for
high blood pressure?
Yes  No
Body Mass Index more than 35 kg/m2?
Yes  No  Not known
Age over 50 years old?
Yes  No
Shirt Collar Size:
17" or greater for Males
16" or greater for Females
Yes  No  Not known
Male?
Yes  No

By clicking submit below, you agree to the following:

  • I understand the importance of providing a truthful health history to assist my doctor in providing the best care possible, and therefore, certify that the above information is correct to the best of my knowledge.
  • I authorize my claim to be sent electronically and my insurance carrier's plan administrator to release information contained in these claims. I agree to the release and exchange of dental/medical information between this office and my family physician, dentist, dental insurance carrier or other responsible person(s) involved in my treatment. I also agree that this information may be exchanged via a secure e-mail.