Medical History Questionnaire for New Patients

Name:* Date of Birth:*

Gender:*

Male Female Prefer not to disclose

Address:*

Home Phone:* Cell Phone:*

Occupation:* Email:*

Who referred you to our office?:*

In case of emergency, we should notify:

Name:*

Relationship:* Day-time Phone:*

Family Doctor: Family Doctor Phone:

(1) Name of Specialist:

(1) Area of Specialty: (1) Phone:

(2) Name of Specialist:

(2) Area of Specialty: (2) Phone:

The dental staff will review the medical form with you and answer any questions. Please fill the following questions:

Any treatment for a medical condition within the past year?

Yes No Not sure/Maybe

If yes, please explain: Last medical checkup?

Any changes to your general health in the past year?

Yes No Not sure/Maybe

If yes, please explain:

List of medications, non-prescription drugs, or herbal supplements (Please include doses taken):

Please also advise if you are taking any medications for blood thinners, osteoporosis, steroids, diabetes, high blood pressure

Any allergies to following medications?

Any allergies ie: hay fever, seasonal, foods?*

Any adverse reaction to medication or injections?

Yes No Not sure/Maybe

If yes, please explain:

Have you ever been hospitalized for any illness or conditions?

Yes No

If yes, please explain:

Please check mark any of the following that apply past or present:

Please elaborate further if you have the following conditions: a. Asthma attacks: (how many times is the puffer used) b. Prosthetic or artificial joint: (please include year of surgery): c. Bleeding problems or disorder: d. Replacement or repair to heart valve, infective endocarditis, heart condition from birth, or heart transplant: (please include year if applicable) e. Heart or blood pressure problems: f. Hepatitis, jaundice or liver disease: (please include year of diagnosis) g. Any conditions that cause immunosuppression: h. Form of disability:

i. Family history of diabetes, heart disease, cancer:

Yes No

If yes, whom?

Do use tobacco or other tobacco-like substances?

Yes No

If yes, frequency and how many years?

Previous Smoker?

Yes No

If yes, how many years smoke free?

Do you drink alcohol?

Yes No

If answered Yes, how many drinks per week?

Women only

Currently pregnant?

Yes No Not sure/Maybe

If yes, what is your expected delivery date?

Thinking of getting pregnant?

Yes No Not sure/Maybe

Are you currently breast feeding?

Yes No

Hormonal imbalances?

Yes No Not sure/Maybe

Dental History Questionnaire

Previous Dental Clinic: Previous Dental Clinic Number:

Last time seen by dentist:* Last cleaning:*

Last dental x-rays:*

History of dental treatment if known:

Fillings: Implant/s:

Crown/s: Root canal/s:

Orthodontic treatment: Gum treatment:

Any complications?

Yes No

Oral hygiene habits:

a. Type of brush:

Electric Manual

b. Bristle type:

Extra soft Soft

Medium Hard

c. Toothpaste name: d. How often do you floss?

e. How often do you brush?

f. Do you use a water pick?

Yes No

g. Mouthwash:

Yes No

h. Do you use fluoride products?

Yes No

Check all that apply:

Are you happy with the colour of your teeth?

Yes No

Are you happy with present oral health/smile?

Yes No

Dental Insurance Information

Primary Insured's Name: Date of Birth: Insurance Company:

Group #: Policy #:

Relationship to subscriber:

Do you have dual coverage?

Yes No

Secondary Insured's Name: Date of Birth: Insurance Company:

Group #: Policy #:

Relationship to subscriber:

PATIENT CONSENT: The privacy of your personal information is a priority in our commitment to providing high-quality dental care. We recognize the importance of safeguarding your personal data and are dedicated to handling it responsibly, ensuring its collection, use, and disclosure are managed with the utmost care. All staff members who have access to your personal information are thoroughly trained in its proper handling and protection. In this consent form, we have detailed the measures our office takes to ensure that:

Only the necessary information is collected from you.
Your information is shared exclusively with your consent.
The storage, retention, and destruction of your personal information adhere to applicable legislation and privacy protocols.
Our privacy practices are fully compliant with the privacy standards set forth by our regulatory body, the Royal College of Dental Surgeons of Ontario, as well as relevant laws.

This office will collect, use and disclose information about you for the following purposes:

To provide safe and efficient patient care.
To ensure continuous high-quality service.
To assess your health needs.
To deliver appropriate healthcare services.
To inform you of available treatment options.
To facilitate communication, including scheduling and confirming appointments, follow-ups, and billing matters.
To offer and provide treatment and care related to the oral and maxillofacial complex and general dental care.
To communicate with other healthcare providers, including specialists and referring or peripheral dentists.
To submit dental claims for third-party adjudication and payment.
To meet legal and regulatory obligations, including providing patient records to the Royal College of Dental Surgeons of Ontario as required by the Regulated Health Professions Act.
To deliver patient charts and records to the dentist’s insurance carrier for liability assessment and damage quantification, if applicable.
To prepare documentation for the Health Professions Appeal and Review Board (HPARB).
To allow potential purchasers, practice brokers, or advisors to assess the practice or conduct an audit in preparation for a practice sale.
To invoice for goods and services.
To process credit card payments.
To collect outstanding accounts.
To ensure compliance with regulatory requirements.
To comply with applicable laws and regulations.

By signing this consent section of the Patient Consent Form, you acknowledge that you have provided informed consent for the collection, use, and/or disclosure of your personal information for the purposes outlined. Should a new purpose arise, we will seek your approval in advance.

Your information may be accessed by regulatory authorities by the Regulated Health Professions Act (RHPA) to enable the Royal College of Dental Surgeons of Ontario to fulfill its mandate under the RHPA, as well as for the defence of any legal matters.

Under no circumstances will our office provide your insurer with your confidential medical history. If such a request is made, we will promptly forward the information to you for review and obtain your explicit consent before any disclosure.

When we receive unusual requests for your information, we will contact you to obtain your permission before releasing any data. Additionally, we may inform you if we believe that such a release would be inappropriate. You have the right to withdraw your consent for the use or disclosure of your personal health information at any time.

PATIENT CONSENT: I have reviewed the information provided above, which outlines how your office will use my personal information and the measures being taken to protect it. I consent to Gumtree Dental Care collecting, using, and disclosing my personal information to the following individual(s).

I filled out this form to the best of my knowledge and confirm that the following information is correct.

Patient/Parent/Guardian Signature:*

Reset Signature