Web Form - Keele Sheppard Dentistry

Medical/ Dental History Form

MEDICAL ALERT:

Personal Information

First Name:

Middle Name:

Last Name:

Gender Identity:

WomanManOtherPrefer Not to Say

Date of Birth:

Home Address:

Cell Phone:

Home Phone:(Optional)

Email Address:

Name of Parents/ Guardian (if under 18 or under guardianship):

Address of Parents / Guardian (if not same as above):

Phone Number of Parents / Guardian:

Emergency Contact Name:

Relationship:

Contact Number:

Name of Family Physician:

Contact Number of Family Physician:

Name of First Medical Specialist:

Area of Specialty:

Contact Number:

Name of Second Medical Specialist (Optional):

Area of Specialty:

Contact Number:

Pharmacy Name:

Pharmacy Contact Number:

Do you have insurance coverage?

YesNoNot Sure

If yes, please provide following details:

(a). Insurance Company Name:

(b). Member Name:

(c). Member Date of Birth:

(d). Policy Number:

(e). Certificate Number:

How did you come to know about us? (This information helps us better serve our community and thank the person/source who referred us to you.)

If Friend/ Family (Please provide their name)

If Other

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

Medical History Questions

1. Are you currently being treated for any medical condition or have you been treated within the past year?

YesNoNot Sure

If Yes Explain Here:

2. When was your last complete medical examination?

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

YesNoNot Sure

If Yes Explain Here:

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

YesNoNot Sure

If yes, please list them:

5. Do you have any allergies?* If yes, please list them using the categories below:

YesNoNot Sure

(a) Medications:

(b) Latex/Rubber:

6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.

YesNoNot Sure

If Yes Explain Here:

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

YesNoNot Sure

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

YesNoNot Sure

9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth
(i.e. congenital heart disease) or a heart transplant?

YesNoNot Sure

10. Do you have a prosthetic or artificial joint?

YesNoNot Sure

11. Do you have any conditions or therapies that could affect your immune system? (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)

YesNoNot Sure

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

YesNoNot Sure

13. Do you have a bleeding problem or bleeding disorder?

YesNoNot Sure

14. Have you ever been hospitalized for any illnesses or operations?

YesNoNot Sure

If Yes Explain Here:

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

16. Are there any conditions or diseases not listed above that you have or have had? If yes, please explain.

YesNoNot Sure

If Yes Explain Here:

17. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?

YesNoNot Sure

If Yes Explain Here:

18. Do you smoke or chew tobacco products?

YesNoNot Sure

19. Have you ever had a previous reaction to metal or metal jewellery?

YesNoNot Sure

20. Have you ever had an adverse reaction to dental freezing, general anaesthetic, penicillin, codeine, aspirin, or other drugs? (circle those that apply)

YesNoNot Sure

If Yes Explain Here:

21. Do you suffer from canker sores or cold sores?

YesNoNot Sure

22. Have you ever fainted? What were the circumstances?

YesNoNot Sure

23. Have you ever experienced any recent unexplained weight change, or increased thirst, appetite, frequency of urination?

YesNoNot Sure

24. Have you ever had a shortness of breath or pains in your chest?

YesNoNot Sure

25. Do you have a heart condition of any kind? (angina pectoris, arrhythmias, or previous heart attack – please circle if any condition apply)

YesNoNot Sure

26. Have you had any organ transplants or joint replacements? If yes, when?

YesNoNot Sure

27. Do you have a prosthetic heart valve or wear a pacemaker?

YesNoNot Sure

28. Have you been told by your medical doctor that you need to take antibiotics before dental treatment?

YesNoNot Sure

29. Are you on any special diet? (e.g., salt restricted diet)

YesNoNot Sure

30. Do you wear contact lenses?

YesNoNot Sure

31. Do you currently use cannabis for non-medical (recreational) purposes, including smoked, vaped, ingested, or topical forms?

YesNoNot Sure

32. Do you currently use injectable medications for weight management or metabolic conditions whether prescribed or non-prescribed?

YesNoNot Sure

If yes, please indicate: Medication name:

Frequency of administration:

DailyWeeklyBi-weeklyOther

Date of last dose:

Prescribed by a regulated healthcare provider?

YesNoNot Sure

33. Do you identify as a patient with a disability?

YesNoNot Sure

If Yes Explain Here:

For WOMEN ONLY:

34. Are you pregnant? If yes, how many months?

YesNoNot Sure

If pregnant, what is the expected delivery date?

35. Are you taking birth control pills?

YesNoNot Sure

36. Are you menopausal or post-menopausal? If yes, are you on hormone replacement therapy?

YesNoNot Sure

37. Are you breastfeeding?

YesNoNot Sure

Dental History Questions

38. Are you nervous during dental treatment?

YesNoNot Sure

39. Have you ever had a negative dental experience?

YesNoNot Sure

If Yes Explain Here:

40. Are you generally tense during dental visits?

YesNoNot Sure

Periodontal History

41. Are you aware of bad breath or a bad taste in your mouth?

YesNoNot Sure

42. Does food routinely get wedged between your teeth?

YesNoNot Sure

43. Does your mouth tend to be dry?

YesNoNot Sure

44. Are your parents or siblings missing any of their natural teeth?

YesNoNot Sure

Habits

45. Do you smoke cigars or cigarettes? Recreational smoking? (circle all that apply) If so, how many per week?

46. Do you chew on pencils, gum, ice cubes, or popcorn kernels? Etc. (circle all that apply)

YesNoNot Sure

47. Do you bite your fingernails, pins, or use a pipe? Etc. (circle all that apply)

YesNoNot Sure

48. Do you drink coffee, tea, or cola drinks?

YesNoNot Sure

49. Do you bite your lips or cheeks regularly?

YesNoNot Sure

50. Do you breathe through your mouth when awake or asleep?

YesNoNot Sure

51. Are you aware if you snore during sleep?

YesNoNot Sure

52. Do you participate in any sports?

YesNoNot Sure

Aesthetics

53. Are you satisfied with the appearance of your teeth and smile?

YesNoNot Sure

54. Would you be interested in knowing about veneers, bonding, tooth whitening, implants, ortho, Invisalign, and other cosmetic options?

YesNoNot Sure

55. On a scale of 1 to 5, please rate your current dental health. Excellent

56. What priority do you place on your dental health? Highest Priority

Signatures

Patient Signature:

Date:

Dentist Signature:

Date:

Name of Parent/ Legal Guardian (for minor patients that are under the age of 18)

Signature of Parent/ Legal Guardian:

Dentist Notes:

Only necessary information is collected about you.
We only share information with your consent.
Storage, retention and destruction of your personal information complies with existing legislation and privacy protocols.
Our privacy protocols comply with privacy legislation, standards of our regulatory body and the law.

How Our Office Collect, Use and Disclose Patient’s Personal Information

Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined below how our office is using and disclosing your information.

This office will collect, use, and disclose information about you for the following purposes:

To communicate with other treating health care providers including specialists and referring doctors
To allow us to distribute health care information and to book and confirm appointments.
To allow us to efficiently follow-up for treatment, care, and billing.
To complete and submit claims for third party adjudication and payment.
To comply with legal and regulatory requirements, including the delivery of patients’ chart and records to the governing bodies when required according to the Regulated Health Professions Act.
To comply with agreements/undertakings entered voluntarily by the member with governing bodies including the delivery and/or review of patients’ charts and for regulatory and monitoring purposes.
To allow potential purchasers, practice brokers/ advisors to conduct an audit in preparation for practice sale.
To deliver your charts and records to the office’s insurance carrier to enable insurance company to assess liabilities and quantify damages, if any.
To invoice for goods and services.
To process credit card payments.
To collect unpaid accounts.
To assist this office to comply with all regulatory requirements and generally with the law.

Put Your Initials: Name of Patient Signature of Patient Name of Parent/ Legal Guardian (for minor patients that are under the age of 18) Signature of Parent/ Legal Guardian Date Name of Parent / Legal Guardian (for minor patients under 18)

Medical/ Dental History Form

Medical History Questions

For WOMEN ONLY:

Dental History Questions

Patient Privacy Consent Form

How Our Office Collect, Use and Disclose Patient’s Personal Information

Patient Consent