(416) 538-8883
415 Bloor Street West Suite 300
Toronto, Ontario M5S 1X6
dentistry@bloordental.com


Bloor Dental Health Centre Medical History Form


We are pleased to welcome you to our practice, and hope to provide you, your family, relatives and friends with the highest quality of dental care.

In order to render the best professional care it is necessary that we become acquainted with the vital information related to each patient. Of course all information is strictly confidential. We appreciate your cooperation in filling out this form carefully and accurately.

PATIENT INFORMATION

Title:

Patient Name:

Date of Birth:

Sex:

Address:

Employer:
Occupation:
CONTACT INFORMATION
Emergency Contact:
Phone Number:
Spouse:
Phone Number:
Family Doctor:
Phone Number:
In the event that we must contact you for scheduling changes, etc, please indicate the BEST PHONE NUMBER during business hours to phone you:
Phone Number:
How did you hear about us?
Internet
Patient Referral
Website
Yellow Pages
Mailer
Other
If you were referred, whom may we thank for their trust in us?
Referral Name:

INSURANCE INFORMATION
Do you have Dental Insurance? Yes   |   No

Group Policy Number:

Certificate or ID Number:

Policy Holder Date of Birth:

Insuring Company:

Medical History

Please select yes or no to the following:

1. May we contact you via email with information on services and events?

2. Is your medical physician or naturopath currently treating you for any reason?

If yes, please specify:

3.Have you ever been hospitalized?

If yes, please specify:

4.Have you ever had a general anaesthetic?

If yes, please specify:

5. Do you bruise easily or bleed excessively when cut?

6.Are you currently taking any medications either prescribed by a MD or NMD?

If yes, please list:

7. Have you ever taken cortisone, steroids, anti-depressants, blood thinners or thyroid medications?

8.Do you smoke?

If yes, how many per day?:

9.Women, are you currently pregnant?

If yes, when are you due?:

Do you have any of the following:

Heart Disease
Hepatitis
Diabetes
Pacemaker or artificial valves
Thyroid problems
Arthritis
Radiation Therapy
Backaches
High Blood Pressure
Blood Disorders/Anemia
Lung or breathing problems
Asthma / Shortness of Breath
Stomach/intestinal problems
Artificial Joint Replacement
Tumors or cancer
Headaches
Heart Murmur
Rheumatic Fever
Liver Problems
Kidney Problems
Tuberculosis
Epilepsy or seizures
STD's, HIV (which one)

10.Do you wake up feeling refreshed after a full nights sleep?

11.Do you snore?

12.Are you allergic to any medication or drugs?

If yes, explain:

13.Do you have any other allergies?

If yes, to what?:

14.Is there anything else concerning your health the dentist should know?

If yes, what?:

Dental History

Approximate date of last dental exam and scaling?

Have you ever had any of the following:

Fillings/restorations
Nitrous oxide (laughing gas)
Extractions
Orthodontics (braces)
Regular cleanings
Caps or crowns
Root Canal Therapy
Dental Implant
Recent Dental X-Rays
Periodontics (gum treatment)
Full or Partial Dentures
An injury to your mouth or jaws

1.Have you ever had a local anesthetic?

If yes, any problems?:

2.Have you ever had an unfavorable dental experience?

If yes, explain:

3.Do you have any fears or anxiety regarding dental visits or treatments?

4. Would you be interested in conscious sedation to alleviate your fears and anxiety?

5.Do you get cold sores or mouth ulcers?

If yes, how often?:

6. Are you happy with the appearance of your smile?

7. Are you interested in whitening your teeth?

8.Is there anything you would like to change about your smile?

Do you presently have or think you may have any of the following:

Loose Teeth
Bad taste in mouth
Dead or abscessed teeth (teeth that have had root canal therapy)
Cavities
Clicking or Sore jaw
Gum Disease
Earaches or headaches
Sensitive Teeth
Unsightly/Broken fillings
Bleeding Gums

In your own words, describe your present dental or needs:

Office Philosophy and Policy
  • We pledge to provide high quality dentistry in the most comfortable manner possible, with the best equipment, materials and up to date technologies.
  • The long term success of our efforts will depend on the patients' willingness to maintain their teeth and prevent any future dental problems.
  • We must make a careful diagnosis in an effort to determine a treatment plan that is best for you. This involves a thorough examination often utilizing a prescribed number of x-rays for accuracy.
  • All urgent dental problems with be attended to the same day, under normal circumstances.
  • Your appointment time will be reserved especially for you. If you are unable to keep the appointment, we require two business days' notice to make any changes or to cancel your reserved appointment otherwise a fee may apply.
  • Our office policy is that payment is rendered at the time of service. In certain circumstances, financial arrangements for payment may be considered.
  • If you have dental insurance, please provide the office with all the necessary information. Our office will gladly submit your claims for you on line, if your insurance carrier is set up to do so.
  • A healthy dentist-patient relationship is based on mutual respect and understanding. Please feel open to discuss with us any aspect of your treatment or fees, at any time.
CONSENT FOR TREATMENT

This is to certify that I consent to the performing of the dental procedures agreed to be necessary and I will assume responsibility for fees associated with those procedures.

Patient Name:
Date:
Patient Initials:
Bloor Dental Health Centre Toronto - Office
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