Conroy Dental Centre -

General Information

Date:

Are you the: patient parent (guardian)

Salutation: Dr. Mr. Mrs. Ms Miss

Last Name:

First Name:

Initial:

Prefers to be called: (if different than above)

Address:

City:

Province:

Postal Code:

Date of Birth:

Age:

Sex:

Marital Status:

Home Phone:

Family Physician:

Family Physician Phone:

Medical Specialist: (if under present care)

Medical Specialist Phone:

Person Responsible for account: Self Spouse Other

Name:

Home Phone:

Address:

City:

Province:

Postal Code:

Employed by:

Phone:

Ext.:

(Above information to be completed only if person responsible for account is other than self)

Your occupation:

Employed by:

Phone:

Ext.:

Spouse employed by:

Phone:

Ext.:

Dental Insurance: Yes No

Insurance Co. Name:

Group Policy No.:

Certif. No.:

Secondary Insurance:

Group Policy No.:

Certif. No.:

% of coverage: Basic % Major % Preventive % Ortho %

Medical Information

In case of emergency, please notify:

Relationship:

Phone:

Closest family relative:

Phone:

Whom may we thank for referring you?

Is another member of your family or relative a patient at our office?

Reason for today's visit: Examination Emergency Other

Is there a dental problem you would like to have taken care of as soon as possible?

The following information is required by the dentist to assist in proper diagnosis and treatment.

1. Have you ever had a serious illness requiring hospitalization or extensive medical care?
Yes No

If so, explain:

2. Are you presently under the care of a physician? Yes No

3. Have you been hospitalized in the last 2 years? Yes No

4. Have you had a medical examination in the last year? Yes No

5. Do you use any prescription or non-prescription medicine including herbal remedies, regularly?
Yes No

Specify:

6. Do you have any allergic condition: i.e. asthma, hay fever, skin rash, food allergies, metal or latex allergies?
Yes No

If so, explain:

7. Do any of these allergic reactions result in headache, shortness of breath, chest constriction, nausea?
Yes No

Specify:

8. Have you ever experienced any unusual reaction to any of the following?

local anaesthesia (freezing) aspirin penicillin iodine
sulfonamide (sulfa) barbiturates (sleeping pills)

or any other medicine? If so, explain:

9. Have you been warned against taking any drug or medication? Yes No

If so, explain:

10. Do you have or have you ever had any of the following? (please mark any/all that apply)

Other:

11. Have you ever had any known contact with the Aids Virus? Yes No

12. Has any member of your family had diabetes? Yes No

13. Do you bruise easily or bleed abnormally? Yes No

14. Do your ankles swell during the day? Yes No

15. Have you had any weight changes recently? Yes No

16. Do you have any blood disorders such as anaemia (thin blood)? Yes No

17. Have you ever had radiation treatment or chemotherapy? Yes No

If so, explain:

18. Have you ever had any injury, surgery or x-ray therapy to your face or jaws? Yes No

19. Do you have frequent severe headaches? Yes No

20. Do you have frequent earaches, ear/throat infections or any hearing difficulties? Yes No

21. Is your eyesight: Good Adequate Poor

22. Are you on a special diet? Yes No

If so, explain:

23. Have you ever fainted? Yes No

24. Do you ever experience shortness of breath or pain in your chest when taking a walk or climbing stairs?
Yes No

25. Do you have any medical or dental implants? Yes No

26. Do you have any disease, condition or problem not listed above that you think the doctor should know about?
Yes No

If so, explain:

27. Is there anything about yourself that we should be made aware of? Yes No

If so, explain:

28. Do you have any medical or dental implants? Yes No

29. WOMEN ONLY - Are you pregnant? Yes No If so, which month are you in?

Are you taking any birth control pills? Yes No

IN ORDER TO AVOID COMPLICATIONS AS A RESULT OF A CHANGE IN YOUR MEDICAL CONDITION, IT IS IMPORTANT THAT YOU NOTIFY OUR OFFICE OF THESE CHANGES.

Dental History

1. How frequently do you see your dentist? 6 months Yearly Other
Last dental visit Last cleaning Last full mouth series of x-rays

2. Have you been given oral hygiene instruction in:
Brushing Flossing Other

3. Are any of your teeth sensitive to:
Cold Sweets Heat Other

4. Do your gums bleed when:
Brushing Flossing Spontaneously

5. Have you ever had any of the following:
Oral surgery Periodontal treatment
Orthodontic treatment Bite adjustment Bite plate or other appliance

6. Do you have any dental implants? Yes No

7. Do you suffer from pain and/or swelling of your gums? Yes No

8. Are you aware of any loose teeth? Yes No

If so, where?

9. Do you chew on only one side of your mouth? Yes No

If so, why?

10. Habits, do you grind or clench your teeth during the day or night? Yes No

do you mouth breathe while awake or asleep? Yes No

do you bite your lips or cheeks regularly? Yes No

do you hold any foreign objects with your teeth? Yes No

11. Does any part of your mouth hurt when clenched? Yes No

12. Does your jaw crack or pop when opened widely? Yes No

13. Do you have any difficulty in opening or closing your jaw? Yes No

14. Do you have any pain in your ears? Yes No

15. Do you gag easily? Yes No

16. Have you experienced any growth or sore spots in your mouth? Yes No

If so, where?

17, Are you concerned about the appearance of your teeth? Yes No

If so, what would you like to see changed?

18. Would you rate your current dental health as: Excellent Good Fair Poor

19. Is your sugar intake: High Medium Low

20. Brushing: Vigorous Light How often?

21. Cleaning aids presently used: Floss Toothpick Other

22. Do you have any emotional concerns regarding your dental visit?
fear pain money embarrassment
other concerns

GENERAL RELEASE

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.

By clicking submit you agree to certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician being contacted if necessary, as this information may be required for my dental care.

WELCOME TO OUR DENTAL OFFICE

General Information

Medical Information

Dental History

GENERAL RELEASE