Web Form - Keele Sheppard Dentistry

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:(if not same as above):

Emergency Contact Name:

Relationship:

Contact Number:

Name of Family Physician:

Contact Number of Family Physician:

Email of Family Physician:

Fax Number:

Name of Medical Specialist (Optional):

Area of Specialty:

Contact Number:

Fax Number:

Pharmacy Name:

Pharmacy Contact Number:

Pharmacy Email:

Fax Number:

Do you have insurance coverage?

If yes, please provide following details:

(a). Insurance Company Name:

(b). Member Name:

(c). Member Date of Birth:

(d). Policy Number:

(e). Certificate Number:

(f). Employer Name:

How did you come to know about us?

Flyer in MailGoogle reviewsLive in neighborhoodWebsiteFriend/ FamilyOther

If Friend/ Family (Please provide their name)

If Other

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

YesNoNot Sure

If yes, please list them:

4. Do you have any allergies?*

YesNoNot Sure

If yes, please list them using the categories below:

(a) Medications:

(b) Latex/Rubber:

5. 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, what kind of reaction?

6. Do you have a prosthetic heart valve or wear a pace maker?

YesNoNot Sure

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

YesNoNot Sure

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

YesNoNot Sure

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

YesNoNot Sure

If Yes Explain Here:

10. Are you on medications or injections for osteoporosis? (e.g. Fosamax, Actonel, Prolia)

YesNoNot Sure

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

YesNoNot Sure

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

Alzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyCold SoresCongenital Heart DisorderConvulsionsDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy/SeizuresExcessive BleedingFrequent CoughFrequent DiarrheaGlaucomaHay FeverHeart AttackHeart MurmurHemophiliaHepatitis A/B/CHerpesHigh Blood PressureHIV/AIDSHives or RashHypoglycemiaKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapsePain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice

13. 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:

14. 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:

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

YesNoNot Sure

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

YesNoNot Sure

17. Have you had any organ transplants or joint replacements?

YesNoNot Sure

If yes, when?

18. Do you currently use injectable medications for diabetes weight management or metabolic conditions whether prescribed or non-prescribed?
( e.g: ozempic, insulin, wegovy, saxenda)

YesNoNot Sure

For WOMEN ONLY:

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

YesNoNot Sure

If pregnant, what is the expected delivery date?

20. Are you breastfeeding?

YesNoNot Sure

Dental History Questions

21. When was your last dental cleaning?

22. When was your last dental examination/visit with a dentist?

23. Are you nervous during dental treatment?

YesNoNot Sure

Periodontal History:

24. Do you feel that you have a bad taste in your mouth?

YesNoNot Sure

25. Does food routinely get wedged between your teeth?

YesNoNot Sure

26. Does your mouth tend to be dry?

YesNoNot Sure

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

YesNoNot Sure

Habits:

28. Do you smoke tobacco, cigars or cigarettes? Recreational smoking? (circle all that apply)

YesNoNot Sure

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

YesNoNot Sure

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

YesNoNot Sure

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

YesNoNot Sure

32. Do you bite your lips or cheeks regularly?

YesNoNot Sure

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

YesNoNot Sure

34. Are you aware if you snore during sleep?

YesNoNot Sure

35. Do you participate in any sports?

YesNoNot Sure

If yes, what kind?

Aesthetics:

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

YesNoNot Sure

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

YesNoNot Sure

38. On a scale of 1 (Poor) to 5 (Excellent), please rate your current dental health

12345

I, the undersigned, certify that all the above medical and dental information is true to the best of my knowledge, and I have not omitted any pertinent information. Should the need arise, I allow my medical doctor to be consulted. I understand that I am financially responsible to the dentist for all necessary treatment.

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:

Your Initials: