Dentist Elora Patient Forms

Patient Information

 
First Name: ____________________ MI: ___ Last: ___________________________________ Preferred Name: _______________
Home Phone: ______________________ Work Phone: ___________________________
Cell Phone: ________________________
Email Address: ___________________________________________________
Date of Birth: _______________________________
Address: _______________________________________ City: ______________
Province: _________________ Postal Code: _______________
 
Name of Physician: _________________________________________
Physician’s Phone: _________________________________
 
In case of Emergency Contact: ____________________________________
Relationship: __________________________ Phone: __________________________
 

Do you have Dental Insurance Coverage?  ______ Yes ______ No

Primary

Insurance Company __________________________   Subscriber's name ____________________

Subscriber's Date of Birth ___________________________

Subscriber's ID number ____________________________  Policy number ___________________

 

Secondary

Insurance Company __________________________   Subscriber's name ____________________

Subscriber's Date of Birth ___________________________

Subscriber's ID number ____________________________  Policy number ___________________

 

How did you hear about our office? _____________________________________________________________________________
Patient Health History
Do you have a history of:
A.I.D.S/HIV Positive
Alcoholism
Allergies
Anemia
Arthritis
Asthma
Blood Disease
Bone Disease
Cancer
Chest Pain
Circulatory Problems
Convulsions/Seizures
Diabetes
Drug Addiction
Excessive Bleeding
Epilepsy
Glaucoma
Hay fever
Head Injuries
Hearing Impaired
Heart Disease
Heart Valve, Murmur
Hepatitis/ Liver Disease
Type(s)
Hepatitis Carrier
High Blood Pressure
Hip or Joint Replacement
HPV
Jaundice
Kidney Disease
Kidney Dialysis
Latex Sensitivity
Lupus
Low Blood Pressure
Malignancies
Mitral Valve Prolapse
Neck and Back Problems
Pacemaker
Prosthetic joints
Psychiatric Care
Radiation Treatment
Respiratory Problems/Disorders
Rheumatic Fever
Rheumatism
Scarlet Fever
Seizures/Fainting Spells
Sinus Problems
Stomach Ulcers
Stroke
Thyroid Disease
Tuberculosis
Tumors or growths
Ulcers
Venereal Disease
Medical Questions
Are you in good health?              Yes                  No
List any medications that you are taking including nonprescription drugs: _______________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
Are you allergic to any medications? Yes No If yes, please list: _______________________________________________________________________________
Have you ever had an allergic reaction to Bananas, Latex or Dental Materials?     Yes       No 
 
Date of last medical exam: _______________________________________________________________________________
Have you ever been hospitalized? Yes No If yes, what was it for? _______________________________________________________________________________
Do you have any disease/problem you think we should know about?         Yes                No _______________________________________________________________________________
Have you ever had a transplant operation that has depressed your immune system?     Yes        No _______________________________________________________________________________
Do you smoke or chew tobacco? Yes No If yes, what and how much in one day? ______________
Are you interested in stopping?             Yes                No
Are you currently under the care of an MD? Yes no If yes, what for?_________________________________________________
Are you taking or have you ever taken bisphosphonates? Fosmax or Actone for osteoporosis, chemotherapy, etc Yes No
If yes, is it taken orally or by IV? ______________________________________________________________________________
 
FOR WOMEN ONLY
Are you taking birth control pills?              Yes              No
Are you pregnant? Yes No Expected delivery date: ___________________________________________________
Is there a possibility of pregnancy?            Yes             No
Are you Nursing/breastfeeding?                 Yes             No
NOTE: Antibiotics (such as penicillin) may alter the effect of birth control pills.
Consult your physician/gynecologist for assistance regarding additional methods of birth control.
 
Dental History Information
Date of your last dental visit? _________________________________________________________________________
Name of your previous dentist: _________________________________________________________________________
Reason for today’s visit? _____________________________________________________________________________
Have you ever had an oral cancer screening?            Yes             No 
How often do you brush your teeth? _______________________
How often do you floss you teeth? _________________________
Do your gums bleed?        Yes                 No
Have you or a family member ever been treated for periodontal disease?           Yes           No 
Have you ever had complications from extractions?            Yes              No 
Have you ever had popping or clicking near your ear when chewing?         Yes             No 
Are you prone to frequent headaches?           Yes             No 
Do you grind or clench your teeth?                Yes               No 
Do you have sores, blisters or swelling on your gums lips or cheeks?        Yes            No 
Have you ever had orthodontic (i.e. braces) treatment?                Yes                No 
Do you snore? Yes No Do you use an appliance to prevent snoring?         Yes              No 
Do you have problems with bad breath?                     Yes                      No
Have you ever had an allergic reaction to a crown, metal fillings or dental appliance? Yes No 
Have you ever used an electric toothbrush? Yes No
Are your teeth sensitive to hot, cold or pressure? Yes No _______________________________________________
On a scale from 1 to 10, with 10 being the highest, how important is your dental health to you?
1 2 3 4 5 6 7 8 9 10
Is there anything you want to change about your smile? __________________________________________________
_________________________________________________________________________________________________
On a scale from 1 to 10, with 10 being the highest, how anxious are you at the dentist office?
1 2 3 4 5 6 7 8 9 10
Have you ever used nitrous oxide or oral sedation for dental appointments? Yes No __________________________
General Release Statement
I certify that I have read, understood and accurately completed the personal medical and dental histories to the best of my knowledge and have not knowingly omitted any information. This information has been reviewed with me, and I consent to my physician being contacted regarding specific medical questions. I authorize the dentist to perform necessary diagnostic procedures and treatment as required to achieve the proper level of dental care.
I understand that I am financially responsible to the dentist for the dental services provided even of my insurance coverage may not be all inclusive.
Payments are to be made at each visit for services rendered.
Cash, Debit, Mastercard and Visa are acceptable forms of payment.
Interest of 2% per month on late payments will be charged automatically.
Patient/Guardian Name ___________________________________________________Date ______________________

Signature _____________________________________________ Reviewed by Dentist _________________________ you would like to here!