ORAL SURGERY – MEDICAL HISTORY FORM Before completing this form, please ensure you have the following information ready: Health Card number and expiry Name and phone number of: Family Doctor, General Dentist, Medical Specialist, and Pharmacy List of medications and allergies Primary and secondary insurance information (if applicable) PATIENT INFORMATIONTitle(Required) Miss Mrs. Ms. Mr. Dr. Name(Required) First Last Date of Birth (DD/MM/YY):(Required) DD slash MM slash YYYY Gender / Self-Identification(Required) Man Woman Non-Binary Other Contact Information:Address:CityPostal Code:(Required)Province:(Required)Home Phone:(Required)Work Phone:Mobile Phone:Height (for sedation purposes):(Required)Weight (for sedation purposes):(Required)Health Card Number:(Required)Health Card Expiry:(Required) DD slash MM slash YYYY POST-SURGERY PICKUP(Name of ride and contact number) Name:Contact #:Mode of transportation home (after surgery):INSURANCE / FINANCIAL INFORMATIONDo you have Insurance Information to provide?(Required) Yes No Insurance Coverage:Do you have Secondary Insurance to provide? Yes No Secondary Insurance Coverage:Policy / Group NumberName of Policy HolderRelationship to Policy HolderPreferred method of payment(Required) Cash Interac Visa Mastercard AMEX FINANCIAL INFORMATION: Person responsible for account(Required) Self Spouse Other PATIENT TYPEPATIENT TYPE(Required) Adult Patient Child Patient Occupation / Employer:Name First Last Phone number of Parent / Guardian (person responsible for the account):CONTACTSFamily Doctor (please write the doctor's name and phone number): Doctor Name:(Required)Phone Number:(Required)General Dentist (please write the dentist's name and phone number): Name:Phone Number:Pharmacy (please write the pharmacy name and phone number): Pharmacy Name:PhoneIn case of emergency, we should notify: First Name:(Required)Phone(Required)Emergency contact relationship:(Required)MEDICAL HISTORYAre you currently being treated for any medical condition, or have you been treated within the past year?(Required) Yes No Last medical checkup (DD/MM/YY): DD slash MM slash YYYY Has there been any change in your general health in the past year?(Required) Yes No Are you taking any medications, non-prescription drugs, or herbal supplements of any kind? If yes, please list all below.(Required) Yes No List of medications, drugs (prescription or non-prescription), herbal supplements:Do you have any allergies?(Required) Yes No If yes, please list:Have you ever had a peculiar or adverse reaction to any medicines or injections?(Required) Yes No If yes, please list:Have you or a family member ever had a peculiar or adverse reaction to anesthesia?(Required) Yes No If yes, please list:Do you have or have you ever had asthma?(Required) Yes No Do you have or have you ever had any heart or blood pressure problems?(Required) Yes No If yes, please explain:Have you ever had any of the following?(Required) Replacement or repair of a heart valve Infection of the heart (infective endocarditis) Heart condition from birth (congenital heart disease) Heart transplant None Do you have a prosthetic or artificial joint?(Required) Yes No Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?(Required) Yes No Have you ever had hepatitis, jaundice, or liver disease?(Required) Yes No Do you have a bleeding problem or bleeding disorder?(Required) Yes No Have you ever been hospitalized for any illnesses or operations?(Required) Yes No Please explain if yes:Do you have or have you ever had any of the following?(Required) Chest pain / angina Rheumatic fever Pacemaker Steroid therapy Seizures (epilepsy) Heart attack Mitral valve prolapse Lung disease Diabetes Kidney disease Stroke / TIA Tuberculosis Stomach ulcers Thyroid disease Shortness of breath Heart murmur Cancer Arthritis Drug / alcohol / cannabis use or dependency Osteoporosis medications (e.g. Fosamax, Actonel) Loss of hearing / difficulty hearing None Are there any conditions or diseases not listed above that you have or have had?(Required) Yes No Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer, heart disease)?(Required) Yes No Do you or have you ever smoked or chewed tobacco products?(Required) Yes No Are you nervous during dental treatment?(Required) Yes No Do you or have you ever taken bisphosphonates or other anti-resorptive / bone strengthening medications?(Required) Yes No If you consume alcohol, how many times a week? Please circle:(Required) Everyday Every other day Every week A few times a month No Do you use recreational drugs? If yes, how many times a week?(Required) Yes No, I do not use recreational drugs Drug FrequencyWOMEN ONLY(Required) Pregnant Nursing Taking birth control N/A Do you clench or grind your teeth?(Required) Yes No Third Choice Have you been diagnosed with sleep apnea?(Required) Yes No Have you ever had orthodontic treatment (braces or Invisalign)?(Required) Yes No Have you experienced any jaw injuries?(Required) Yes No Have you ever had implant surgery in your jaw?(Required) Yes No DENTAL HISTORYHave you ever had any complications or issues with previous dental treatment? Please explain below:(Required)Please list anything else not mentioned above regarding your past dental history:(Required)CANCELLATION / MISSED APPOINTMENTS Your appointment time has been reserved exclusively for you to see the specialist. We ask that you give us at least 5 business days' notice when cancelling your scheduled appointment so that we may offer the time to another patient. If you must cancel or change your appointment, please call 613-761-1203. GENERAL RELEASE I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history to the best of my ability and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. 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. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the Province of Ontario. Name(Required) First Last Signature(Required)Date(Required) DD slash MM slash YYYY
