Dentistry on Dufferin

Toronto

2992 Dufferin St. Toronto,
ON, M6B 3T3
dentistryondufferin@gmail.com
Tel: 416-785-5555

In an effort to serve you better, please complete the following. We will be glad to assist you. PLEASE PRINT.

Patient Information

A parent or guardian will be responsible for decisions on my treatment

Yes No

First Name

Initial Name

Last Name

Street Address

Apt

City

Province / State

Postal Code

Date of Birth

Home Tel

Work Tel

Email Address

Emergency Contact

Tel

Family Doctor

Tel

Referring Doctor

Tel

Financial Information

Method of payment:

Cash Cheque Credit Card Insurance Other

Person responsible for financial matters:

Self Spouse Parent/Guardian Other

If different from above

First Name

Initial Name

Last Name

Street Address

Apt

City

Province / State

Postal Code

Date of Birth

Home Tel

Work Tel

Do you have Dental Insurance?

Yes No

Primary Insurance

Ins. Company

Tel

Employer/Policy Holder

Ins. Yr. End

Policy#

Certificate#

ID#

Max Cov.

% Coverage for Basic

Maj. Restorative

Orthodontic

Secondary Insurance

Ins. Company

Tel

Employer/Policy Holder

Ins. Yr. End

Policy#

Certificate#

ID#

Max Cov.

% Coverage for Basic

Maj. Restorative

Orthodontic

General Release

I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

Signature Self Parent/Guardian

Print Name

Date

MEDICAL HISTORY (this information will remain confidential)

Date

1. Are you presently under the care of a physician? If so, explain.

Yes No

2. Have you ever been hospitalized? Explain.

Yes No

3. Are you taking any drugs or medication at this time?

4. Have you ever had any adverse effect to any of the following?

Antibiotic - Penicillin Sulfonamide Others Aspirin Codeine Barbiturates (Sleeping pills) Darvon Local Anaesthetic None

5. Have you ever been warned against using any other medications? Which?

Yes No

6. Have you ever taken prolonged medical or non-medical drugs? Which?

Yes No

7. Do you suffer from any allergies (hay fever, latex etc.)? Which?

Yes No

8. Do you bruise easily or have prolonged bleeding?

Yes No

9. Do you smoke? How much per day?

Yes No

10. Have you ever fainted, had shortness of breath or chest pains?

Yes No

11. WOMEN Are you pregnant?

Yes No

Using birth control?

Yes No

Reached menopause?

Yes No

12. Do you have or have you ever had any of the following? Please ✓ appropriate boxes. NONE

A.I.D.S. Cortisone/steroid High/Low Blood pressure Psychiatric disorders Anemia Diabetes H.I.V. Positive Radiation/Chemotherapy Angina pectoris Drug/alcohol dependence Hodgkin’s disease Rheumatic/Scarlet fever Anorexia nervosa Emphysema Hyper (Hypo) Glycemia Sickle Cell disease Artificial Heart valve Epilepsy Hypertension Sinus trouble Arthritis/rheumatism Glandular disorders Jaundice Stomach/intestinal problems Artificial joints (hips, knees) Glaucoma Kidney disease Stroke Asthma Head/Neck injuries Liver disease Thyroid disease Blood disorders Heart disease/attack Leukemia Tuberculosis Bronchitis Heart murmur Lung disease Ulcers Bulimia Heart pacemaker/surgery Malignant hypothermia Venereal disease Cancer Heart rhythm disorder Mental/nervous disorder Others Circulation problems Hepatitis A/B/C Mitral valve prolapse Others Congenital heart lesions Herpes Organ transplant/implant Other

13. CHILDREN Have you recently had any of the following (approximate date)?

Chicken Pox Measles Mumps Tonsillitis NONE

DENTAL HISTORY

1. What is the reason for today’s visit?

Emergency Examination Others

2. How frequently do you see a dentist?

3-6 months Annually Others

3. When was your last dental visit?

Last X-Ray?

4. How often do you brush per day?

Floss?

Use anti-bacterial rinse??

5. Are your teeth sensitive to:

Cold Sweet Heat Others

6. Do your gums bleed when:

Brushing Flossing Never

7. Do your gums feel swollen or tender?

Yes No

8. Do you have bad breath or a bad taste in your mouth?

Yes No

9. Do your jaws crack, pop or grate when you open widely?

Yes No

10. Do you grind or clench your teeth?

Yes No

11. Do you have food catch between your teeth?

Yes No

12. Have you ever had local anaesthetic (freezing)?

Yes No

Any complications?

Yes No

13. Have you ever had any problems with previous dental treatments?

Yes No

14. Have you ever had any of the following:

Bridgework Crowns or Caps Full or Partial Dentures Orthodontic (braces) Periodontal (Gums) Root Canal

15. Are you satisfied with your teeth? Specify

Yes No

By clicking submit, your information will be securely transmitted to our clinical records department.