NEW PATIENT REGISTRATION

New patients are kindly asked to fill out our confidential online patient registration form before their first visit. Your dental and medical history are essential to determine the course of your treatment and help us provide you with optimum dental care.

MEDICAL HISTORY  QUESTIONNAIRE

MEDICAL ALERT:

Name: In Case of Emergency, we should notify:
First Name: Name:
Last Name: Relationship:
Date of Birth: / / (mm/dd/yyyy) Day-time Phone:
 Address (Home): Name of family doctor:
City:      Phone or address:
Postal Code:  
Home Phone: (1) Name of medical specialist:
Cell Phone: Area of speciality:
Email: Phone or address:
Confirm Email:  
Address (Bus.): (2) Name of medical specialist:
City:      Area of speciality:
Postal Code: Phone or address:
Bus. Phone:  
Occupation:    
Employer:    
Who referred you to our office?
       
The following information is required to enable us to provide you with the best possible dental care.
All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why?
 
2. When was your last medical checkup?
3. Has there been any change in your general health in the past? If yes, please explain.
 
4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list.
 
5. Do you have any allergies? If you answered yes, please list using the categories below:
 
 
6. Have you ever had a peculier or adverse reaction to any medicines or injections? If yes, please explain.
 
7. Do you have or have you ever had asthma?
8. Do you have or have you ever had any heart or blood pressure problems?
 
9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (.i.e. congenital heart disease) or a heart transplant?
 
10. Do you have a prosthetic or artificial joint?
  Wat year was it done?
11. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?
 
12. Have you ever had hepatitis, jaundice or liver disease?
13. Do you have a bleeding problem or bleeding disorder?
14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
 
15. Do you have or have you ever had any of the following? Please check.



16. Are there any conditions or diseases not listed above that you have or have had? If so, what?
 
17. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)
     
18. Do you smoke or chew tobacco products?
19. Are you nervous during dental treatment?
20. FOR WOMEN ONLY: Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?
 
Initials:   
     
 
For the best of my knowledge, the above information is correct.

                           

 

  • County Dental Care Chapel Street, Picton, Ontario
  • 613-476-2353
  • www.countydentalcare.com
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