Please enter your sign-up information Personal information Patient full name * Gender * MaleFemale Date of birth: mm/dd/yyyy * Employer Who referred you Contact information Street address * Apartment No. Buzzer No. City * Postal/Zip code * State/Province * OntarioAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutPrince Edward IslandQuebecSaskatchewanYukon Home phone Business phone Cell phone Email address The following information is essential for proper diagnosis and treatment. It is also extremely important for your safety! PLEASE READ CAREFULLY AND FILL OUT COMPLETELY All information is CONFIDENTIAL and cannot be released to ANYONE without your consent. Questions marked by (*) are required to answer for successful sign up! MEDICAL - HISTORY 1. Your Physician's Name 1. Address 1. Phone 2. Date of Last Visit: 2. Reason: 3. What medication(s) are you taking? 4. What medication(s) are you ALLERGIC to? PLEASE CHECK EITHER ( YES ) OR ( NO ) FOR ALL OF THE FOLLOWING. 5. Have you ever had ANY adverse reaction to, or been advised NOT to take any of the following medication(s)? Anti-inflamatories YesNo Aspirin YesNo Codeine YesNo Erythromycin YesNo Anti-inflammatories YesNo Penicilln YesNo Tylenol YesNo Local Anaesthetic YesNo General anaesthetic YesNo Nitrious oxide (laughing gas) YesNo Other MEDICATIONS? 7. Have you ever had, or been treated for, or do you currently have ANY of the following? Addiction YesNo Allergy YesNo Anemia, Blood Disorders YesNo Arthritis YesNo Asthma YesNo Cancer YesNo Diabetes YesNo Eating Disorder YesNo Epilepsy YesNo Heart Attack, Coronary Disease or Heart Surgery YesNo Heart Murmur, Mitral Valve Prolapse, Rheumatic Fever YesNo High/Low Blood Pressure YesNo TB or Lung Disease YesNo HIV YesNo Hepatitis YesNo Kidney Disease or Dialysis YesNo Mental Illness, Anxiety, Depression YesNo Prosthetic Valves, Joints or Plates YesNo Sinusitis YesNo Stroke YesNo Thyroid problem YesNo Ulcer YesNo 8. List ANY serious illnesses you have had: 9. List ANY operations you have had: 10. Have you ever fainted? YesNo Do you experience shortness of breath or exertion? YesNo Chest pains? YesNo 11. Do you require an extra pillow(s) when you recline or sleep? YesNo How many? Do your ankles swell? YesNo 12. Has your weight changed recently? YesNo What amount? Lbs: Are you now or have you ever been on a diet? YesNo If yes, for what reason? 13. Do you bruise easily or bleed abnormally? YesNo Is there any history of family disease? YesNo If yes, list: 14. WOMAN ONLY: Are you pregnant? YesNo How many month? mos: DENTAL - HISTORY 1. Have you ever had any injury, surgery or radiation therapy on your face or jaws? YesNo If so, describe: 2. Have you ever had a complete set or x-rays or a panorex taken? YesNo If so, when? 3. When was your last dental visit? Purpose? Were x-rays taken? YesNo 4. What dental condition concerns you at the present? 5. What is the history of this condition? 6. Have you had regular (annual or semi-annual) dental examinations in the past? YesNo If not, why not? 7. Have you had ANY teeth extracted? YesNo If so, when? Describe any complications 8. Have you had local anaesthetic before? YesNo Describe any adverse reactions: 9. Are you conscious of bad breath? YesNo Do your gums feel itchy, swollen or bleed? YesNo 10. have you ever been instructed in the proper home care of your mouth? YesNo Do you floss? YesNo Rubber tip? YesNo 11. Do you chew easily and throughly? YesNo Which side do you chew on? LeftRightBoth sidesNot sure 12. Are you aware of clenching or grinding your teeth? YesNo Does your jaw ever click, crack or lock? YesNo Which side? LeftRightBoth sidesNot sure 13. Does it ever get sore stiff or painful? YesNo Have you ever had any TMJ therapy? YesNo If so, describe 14. Are you tense during dental visits? YesNo Have you ever had Nitrious Oxide (laughing gas) for dental treatment? YesNo 15. Are you satisfied with the appearance of your teeth? YesNo What would you change? 16. Are you interested in discussing cosmetic options (re: possible changes to tooth colour, shape, size, spacing or position)? YesNo 17. Is there any other information you think could be a factor in determining your treatment? YesNo If so, explain: I, the undersigned, certify that I have read and understand all of the above questions, and that all of the above information is correct and that I have not omitted any pertinent information. I also authorize release, to my insuring company/plan administrator, the information contained in claims submitted electronically. Below to be filled in the dental office! Doctor's Signature: Date: Patient's Signature: Date: