Patient Information Form

A parent or guardian will be responsible for decisions on my treatment. (optional)

Yes

First Name

Initial

Last Name

Address

City

Postal Code

Emergency Contact

Family Doctor (optional)

Email Address

Medical History (optional)

This information will remain confidential

1. Are you presently under the care of a physician?

Yes

Please explain.

2. Have you ever been hospitalized?

Yes

Explain

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

Yes

A) Drug (optional)

Reason (optional)

B) Drug (optional)

Reason (optional)

C) Drug (optional)

Reason (optional)

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

Antibiotic - Penicillin

Sulfonamide

Other

Aspirin

Barbuturates (sleeping pills)

Condeine

Darvon

Local Anaesthetic

None

Other (optional)

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

Yes

Which?

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

Yes

Which? (optional)

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

Yes

Which? (optional)

8. Do you bruise easily or have prolonged bleeding?

Yes

9. Do you smoke?

Yes

How much per day? (optional)

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

Yes

11. For women (optional)

Are you pregnant? (optional)

Yes

Using birth Control? (optional)

Yes

Reached menopause? (optional)

Yes

13. For children (optional)

Have you recently had any of the following (approximate date)? (optional)

Chicken Pox

Strep Throat

Measles

Tonsilitis

Mumps

None

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

Emergency

Examination

Other

2. How frequently do you see a dentist?

3-6 months

Annually

Other

3. When was your last dental visit?

Last X-Ray? (optional)

4. How often do you brush per day?

Floss? (optional)

Use anti-bacterial rinse? (optional)

5. Are your teeth sensitive to:

Cold

Sweets

Heat

Other

None

6. Do your gums bleed when:

Brushing

Flossing

Never

7. Do your gums feel swollen or tender?

Yes

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

Yes

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

Yes

10. Do you grind or clench you teeth?

Yes

11. Do you have food catch between your teeth?

Yes

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

Yes

Any complications?

Yes

Specify (optional)

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

Yes

Specify (optional)

14. Have you ever had any of the following:

Bridgework

Orthodontic (braces)

Crowns or Caps

Periodontal (gums)

Full or Partial Dentures

Root Canal

None

15. Are you satisfied with your teeth?

Yes

Specify (optional)

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 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.

Important Covid-19 UpdateLearn More

+ +

EMERGENCY TREATMENT

3296 Keele Street. Toronto, ON M3M 2H7

Patient Information Form