Burlingwood Full Patient Form

Patient Information

First and Last Name

Home Phone Number

e.g. 123-456-7891

Cell Phone Number

e.g. 123-456-7891

Email Address

Place of Birth

Date of Birth

Street Address

City

Province

Postal Code

If you were referred by a patient, enter their name here:

Employer's Name:

Occupation:

Previous Dentist:

Family Physician:

In case of emergency please notify - Name, relationship and number

Insurance

Dental plan insurance company if applicable

Group Policy #

Certificate/Member ID #

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. Your data is stored in compliance with the PIPEDA (Personal Information Protection and Electronic Documents Act) of Canada.

Please fill in the following as best as you can:

Are you in good health?

Yes No

Has there been any change in your general health in the past year?

Yes No

Please Explain:

Are you currently taking any medication, non-prescription drugs or herbal supplements of any kind?

Yes No

Please Specify Medications:

Do you have any allergies? (e.g. penicillin, latex/rubber product)

Yes No Other

Please Specify:

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

Yes No

Please Specify:

Do you bleed or bruise easily?

Yes No

Do you have a heart problem of any kind? If yes, please explain below:

Yes No

Please Explain:

Have you ever had a heart murmur, mitral valve prolapse or rheumatic Fever?

Yes No

Have you ever been advised by your doctor to take antibiotics before dental treatment?

Yes No

Have you ever been exposed to Hepatitis or Jaundice?

Yes No

Women only: Are you pregnant or breast-feeding?

Yes No

Have you ever been hospitalized for any illness or operations?

Yes No

Please Explain:

Have you ever had any illness not included above?

Yes No

Please specify:

Dental History

Have you ever had a dental examination with a full series of x-rays of your teeth and jaws?

Yes No

When was your last dental visit?

Were there any complications?

Yes No

Please specify:

Your Smile

Are you happy with the appearance of your smile/teeth?

Yes No

Are your teeth sensitive to:

Cold

Sweets

Heat

Other

Please specify:

Do your gums bleed when:

Brushing

Flossing

Spontaneously

Do your gums feel swollen or tender?

Yes No

Does food lodge between your teeth?

Yes No

Does your jaw crack, pop or grate when opened widely?

Yes No

Do you grind or clench your teeth?

Yes No

Your information will be encrypted.