Dental Patient Information Form In Toronto | Smile Dentistry at Downsview Park

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

Yes

No

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

Yes

No

2. Have you ever been hospitalized?

Yes

No

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

Yes

No

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

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

Yes

No

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

Yes

No

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

Yes

No

8. Do you bruise easily or have prolonged bleeding?

Yes

No

9. Do you smoke?

Yes

No

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

Yes

No

Are you pregnant? (optional)

Yes

No

Using birth Control? (optional)

Yes

No

Reached menopause? (optional)

Yes

No

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

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

No

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

Yes

No

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

Yes

No

10. Do you grind or clench you 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

Orthodontic (braces)

Crowns or Caps

Periodontal (gums)

Full or Partial Dentures

Root Canal

None

15. Are you satisfied with your teeth?

Yes

No

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.

EMERGENCY TREATMENT

3296 Keele Street. Toronto, ON M3M 2H7

Patient Information Form