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Clinic
About
Team
New Patient
Medical Form
Emergency Care
Services
Early Treatment
Adolescent Treatment
Adult Treatment
Braces
Invisalign®
Gallery
Contact
FR
Medical Form
Step
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5
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Basic Information
To better serve you, please complete the form below. The form usually takes 5 to 15 minutes and gives you the best possible service. Thank you!
Name
*
First Name
Last Name
Gender
*
Male
Female
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone
*
Email
*
Date of Birth
*
MM slash DD slash YYYY
In an emergency, contact:
*
Name of your dentist
Person who referred you
Reason for your visit
Medical History
Are you currently followed by a doctor?
Yes
No
Name of doctor, and phone number:
*
Do you currently take medication or in the last six months?
Yes
No
Please list all medications:
*
Have you ever suffered or are you suffering from...
Cardiac disorders (myocardial infarction, angina, valve problems, breathing problems)?
Yes
No
Rheumatic fever?
Yes
No
Prolonged bleeding?
Yes
No
Anemia?
Yes
No
Blood pressure?
Yes
No
Frequent colds or sinusitis?
Yes
No
Tuberculosis or lung problems?
Yes
No
Stomach problems, digestive disorders?
Yes
No
Liver problems (hepatitis A, B, C, cirrhosis)?
Yes
No
Kidney problems?
Yes
No
Diabetes?
Yes
No
Thyroid problems?
Yes
No
Skin diseases?
Yes
No
Eye Problems?
Yes
No
Arthritis?
Yes
No
Epilepsy?
Yes
No
Frequent headaches?
Yes
No
Dizziness, fainting?
Yes
No
Earache?
Yes
No
Asthma?
Yes
No
Sleep apnea?
Yes
No
Are you a smoker?
Yes
No
Have you ever had radiation treatment or chemotherapy?
Yes
No
Do you have artificial joints?
Yes
No
Do you have any allergies to food or medications?
Yes
No
Do you have an allergy to latex or any metal?
*
Do you have an allergy to latex or any metal?
Yes
No
Have you ever been hospitalized or undergone surgery other than dental?
Yes
No
Please describe the date, surgery type, doctor and hospital:
*
Comments:
*
Dental History
Last dental visit
*
0-6 months
6-12 months
12 months or more
Treatments received
Do you have pain in the mouth or joints?
Yes
No
Have any permanent teeth been removed?
Yes
No
Have any permanent teeth been injured or chipped by an accident?
Yes
No
Do you have any head or face injuries?
Yes
No
Do you have any speech problems?
Yes
No
Have you ever sucked a thumb or fingers?
Yes
No
Until what age?
*
Do you breathe predominantly by the mouth?
Yes
No
Do you have tongue thrust?
Yes
No
Do you grind or clench teeth?
Yes
No
Do you play a wind instrument?
Yes
No
Have you seen another orthodontist?
Yes
No
Do you have any recent radiographs? (x-rays)
Yes
No
Do you have any clicking, cracking or pain in jaw?
Yes
No
Have you ever had the following dental treatment or services...
Demonstration of oral hygiene?
Yes
No
Gum treatment?
Yes
No
Orthodontic treatment (braces)?
Yes
No
Root canal?
Yes
No
Dental surgery or extraction?
Yes
No
Dental implants?
Yes
No
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