Medical-Dental Information for Adult Patient

First name:

Last name:

Sex: MaleFemaleOther

Date of birth:
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Month: —Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Year:

Preferred language: EnglishFrenchOther

Status: SingleMarriedDivorcedWidowedCommon-law

Mailing address:

City:

Province:

Postal Code:

Home phone:

Cell phone:

Work phone:

Email:

Have you received a date for your consultation appointment : YesNo

If yes, please indicate what date you received:
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Month: —Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Year:

Family physician/paediatrician

Family dentist

How did you hear about our office?

Who may we thank for recommending us?

What activities/hobbies or sports do you enjoy?

Please check any of the following if you have ever been told that you have the condition
or received treatment: Heart conditionAccidents to your head, face and/or teethHigh or low blood pressureThyroid problemsRheumatic heart disease or rheumatic feverEpilepsyDiabetesArthritis / joint problems (replacement)Liver disease or hepatitisMuscle disordersAsthmaNickel/metal sensitivityBleeding disordersBone fractureTumor or cancerAIDS or HIV positive infectionOtherNone

If you have chosen "Other" in the previous question, please explain

Are you allergic to any food, drugs, medicine or latex? YesNo

If yes, please indicate what the allergy is

Do you have a heart condition or any condition that requires antibiotics before dental procedures?YesNo

If yes, please explain

Are you under the care of a doctor at the present time?YesNo

If yes, please explain

Have you been hospitalized in the last 2 years?YesNo

If yes, please explain

Do you suffer from snoring or sleep apnea?YesNo

Are you currently taking any medication?

Have you seen your dentist recently?YesNo

Have you been evaluated by an orthodontist in the past?YesNo

Have you had orthodontic treatment in the past?YesNo

Do you have any habits such as finger sucking, mouth breathing, tongue thrusting, nail biting or difficulties chewing?YesNo

Have you had periodontal (gum) treatment in the past?YesNo

Have you ever had any injuries to your teeth and/or face?YesNo

Have you ever experienced any of the following issues (TMJ problems): Grinding and/or clench your teethFrequent Headaches/migrainesJaw locking open or closeNoise in the jaw joint when opening or closingJaw pain/discomfort