Oral surgery medical history

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 INFORMATION

Title(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:

City

Postal 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 INFORMATION

Do you have Insurance Information to provide?(Required)

Yes

Insurance Coverage:

Do you have Secondary Insurance to provide?

Yes

Secondary Insurance Coverage:

Policy / Group Number

Name of Policy Holder

Relationship to Policy Holder

Preferred method of payment(Required)

Cash

Interac

Visa

Mastercard

AMEX

FINANCIAL INFORMATION: Person responsible for account(Required)

Self

Spouse

Other

PATIENT TYPE

PATIENT TYPE(Required)

Adult Patient

Child Patient

Occupation / Employer:

Name

First Last

Phone number of Parent / Guardian (person responsible for the account):

CONTACTS

Family 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:

Phone

In case of emergency, we should notify:

First Name:(Required)

Phone(Required)

Emergency contact relationship:(Required)

MEDICAL HISTORY

Are you currently being treated for any medical condition, or have you been treated within the past year?(Required)

Yes

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

Are you taking any medications, non-prescription drugs, or herbal supplements of any kind? If yes, please list all below.(Required)

Yes

List of medications, drugs (prescription or non-prescription), herbal supplements:

Do you have any allergies?(Required)

Yes

If yes, please list:

Have you ever had a peculiar or adverse reaction to any medicines or injections?(Required)

Yes

If yes, please list:

Do you have or have you ever had asthma?(Required)

Yes

Do you have or have you ever had any heart or blood pressure problems?(Required)

Yes

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

Do you have a prosthetic or artificial joint?(Required)

Yes

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?(Required)

Yes

Have you ever had hepatitis, jaundice, or liver disease?(Required)

Yes

Do you have a bleeding problem or bleeding disorder?(Required)

Yes

Have you ever been hospitalized for any illnesses or operations?(Required)

Yes

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

Are there any conditions or diseases not listed above that you have or have had?(Required)

Yes

Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer, heart disease)?(Required)

Yes

Do you or have you ever smoked or chewed tobacco products?(Required)

Yes

Are you nervous during dental treatment?(Required)

Yes

Do you or have you ever taken bisphosphonates or other anti-resorptive / bone strengthening medications?(Required)

Yes

If you consume alcohol, how many times a week? Please circle:(Required)

Everyday

Every other day

Every week

A few times a month

Do you use recreational drugs? If yes, how many times a week?(Required)

Yes

No, I do not use recreational drugs

Drug Frequency

WOMEN ONLY(Required)

Pregnant

Nursing

Taking birth control

Do you clench or grind your teeth?(Required)

Yes

Third Choice

Have you been diagnosed with sleep apnea?(Required)

Yes

Have you ever had orthodontic treatment (braces or Invisalign)?(Required)

Yes

Have you experienced any jaw injuries?(Required)

Yes

Have you ever had implant surgery in your jaw?(Required)

Yes

DENTAL HISTORY

Have 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 613-831-8000.

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