Medical Information Record – Adult

You may complete the Patient History form below and submit the data online. You can also download and print the following 2 PDF files and bring the completed forms to your first visit. The forms are compliant with Personal Information Protection and Electronic Documents Act (PIPEDA). Please fill out all items to your best knowledge. Fields marked with an asterisk(*) are required.

    ADULT ORTHODONTIC PATIENT INFORMATION

  • MaleFemaleX
  • SingleMarriedDivorcedWidowed
  • DOES PATIENT HAVE ORTHODONTIC INSURANCE COVERAGE? YesNo

    PRIMARY INSURANCE

    SECONDARY INSURANCE

    MEDICAL HISTORY

    Have you been diagnosed or treated for any of the following?

  • DiabetesHeart ConditionCancerDrug/Alcohol AbuseTuberculosisHepatitisHeart MurmurEmotional ProblemsAids/HIV positiveEpilepsyRadiation TreatmentSpeech/Hearing ProblemsLung DisordersDifficulty BreathingSinus ProblemsVision ProblemsAnemiaPsychiatric Problems
  • Are you in good health? YesNo
  • Are you taking any medications (include over-the-counter) YesNo
  • Have you ever been diagnosed with Osteoporosis, bone density concerns or taken Bisphosphonates?
    YesNo
  • List any daily medications you are presently taking:
  • Have adenoid and/or tonsils been removed? YesNo

    Are you allergic to any of the following?

  • AnestheticsAspirinAmoxicillinCodeineCyclosporinsErythromycinLatexNickelPenicillinSulfa DrugsTetracyclineOTHER
  • Please List any other medicine or material you may be allergic to:

    DENTAL HISTORY

  • Have had complications following dental treatment? YesNo
  • Ever injured any teeth? YesNo
  • Ever injured jaw or face? YesNo
  • Currently have cavities/toothaches that need treatment? YesNo
  • Needs to be pre-medication before dental treatment? YesNo

    AUTHORIZATION

    I have examined the above information and it is true and correct.