EMERGENCY PATIENT MEDICAL HISTORY

PATIENT INTAKE QUESTIONNAIRE
Your cooperation in completing this questionnaire is essential to providing you with the highest standard of dental care. Please answer the questions accurately as you can. All information is strictly confidential and will remain with this office. We understand the importance of protecting your personal information.
PLEASE BE PATIENT, IT IS DETAILED

QUESTIONS WITH * MUST BE ANSWERED
Patient Name *

Title First Name Middle name Last Name
PREVIOUS DENTIST / OFFICE INFORMATION:

Fill in what you can!
Dentist name
Dental office name
Phone

Area Code Phone Number
When was your last complete exam - (code 01103, 01102, 01101 in Ontario). If you book a complete exam, verify with your insurance carrier if you are covered. Most plans have a 3-5 year insurance coverage exclusion for complete exams. If you had a complete exam within the last 5 years, your insurance might not cover you for another one. *

I ACCEPT RESPONSIBILITY FOR PAYMENT IF I DO NOT HAVE COVERAGE THROUGH MY INSURANCE
Date of last bite wing radiograph- (Ontario code 02141, 02142, 0214# etc...) *
Date of last Panoramic radiograph- ( Ontario code 02601 )
Medical Alert:
I release you from all legal responsibility that may arise from this authorization. If I have not verified the dates of my last complete exam or radiographs, my insurance may not cover the treatment and I understand that I am responsible to pay all incured expenses.
Patient Parent Guardian Signature *

Clear
Date *

Month Day Year
Date
Patient Name: *

Title First Name Middle name Last Name
Preferred Name:

Title First Name Last Name
Patient Gender *
Spouses / Partner Name:
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Patient Birth Date *

Month Day Year
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Email *
example@example.com
Please check your preferred method of contact for appointment confirmation:

E-MAIL CELL PHONE WORK PHONE HOME PHONE TEXT MESSAGE
Please indicate where you DO NOT WANT TO BE DISTURBED.

Work Phone
Employer
Occupation
Are you a full-time student?

Yes No
If yes, name of school
Marital Status:

Single Married Divorced Separated Domestic Partner Prefer Not To Say
Who may we thank for referring you / How did you hear about our office:

Friend / Family Google search Reviews location
Insurance - Primary
Subscriber Name
Relationship to Patient
Subscriber DOB
Subscriber ID
Subscriber Employer
Insurance Company Name
Group / Policy / Plan Number
Insurance - Secondary
Subscriber Name
Relationship to Patient
Subscriber DOB
Subscriber ID
Subscriber Employer
Insurance Company Name
Policy / Plan / Group Number
I WILL ASSUME RESPONSIBILITY FOR FEES ASSOCIATED WITH THESE PROCEDURES. I AUTHORIZE RELEASE, TO MY INSURER/PLAN ADMINISTRATOR, THE INFORMATION CONTAINED IN CLAIMS AND ESTIMATES MAILED OR SUBMITTED ELECTRONICALLY.

I Understand
IN CASE OF EMERGENCY:
Name
Relationship
Phone

Area Code Phone Number
DENTAL SPECIALIST INFORMATION:

If you have one or two!
Name
Phone

Area Code Phone Number
Name
Phone

Area Code Phone Number
DENTAL HISTORY:
If you have a main concern or emergency, please indicate below.
Take Photo of are of concern
When did the pain or concern begin?

Pain Level?

	1	2	3	4	5

1 is None, 5 is Strong

Select on or more:

	yes	no
Pain to Cold
Pain to Hot
Spontaneous Pain
Pain Medication helps
Pain keeping me up at night
Pain when bitting down
Pain when releasing from a strong bite

I am concerned about the appearance of my teeth or my smile. *

Yes No
In social situations, I am sometimes embarrassed by my teeth or my smile. *

Yes No
There are some things about my upper/lower front teeth that I would like to change. *

Yes No
I have old fillings or previous dental treatment that is no longer satisfactory to me. *

Yes No
I am interested in learning more about cosmetic dentistry. *

Yes No
Have you ever had orthodontic treatment? Braces or Invisalign? *

YES NO
Are you interested in Orthodontics Treatment? *

YES NO
If interested in orthodontic treatment, please state what you would change about the appearance of your teeth.
I am interested in whitening my teeth. *

Yes No
Normal frequency for dental hygiene appointments? (ex. Every 6 mo) *

Every 6 months Every 9 months Alternate with periodontist
How often do you brush? When? Electric or manual toothbrush? Choose all that apply. *

1 x day 2 x day Morning Evening Manual Toothbrush Electric Toothbrush
How often do you floss? *

Everyday More than 2 x week Less than 2 x week 1 x Month Rare Never
Do you use mouthwash? What type? *

YES ( Indicate what type below ) NO
Other types of oral health instruments ? *

YES ( Indicate what type below ) NO
Are you aware of any lump, growths or swelling in your mouth? *

YES NO
Food catching between your teeth? *

YES NO
Are your teeth sensitive to hot/cold? *

YES NO
Are your teeth sensitive to biting or chewing? *

YES NO
Do you grind your teeth? *

YES NO
Any TMJ issues? *

YES NO
Headaches when you wake up? *

YES NO
Have you had a bite splint / nightguard? *

YES NO I have one but i don't use it
Have you had periodontal treatment? *

YES NO
Have you had maxillofacial surgery other than wisdom teeth removal? *

YES NO
Do you participate in contact sports? *

YES NO
Do you have a Sportsguard? *

YES NO
Have you had a serious injury to your mouth or head? *

YES NO
Do you have any of these symptoms. Difficulty swallowing, Throat pain, Ringing in ear, Neck pain, Throat/Neck pain when turning head, Short duration loss of vision, Frequent headaches/migraines, Dizziness, Pain radiating to ear? ( Eagle's syndrome ) *

YES NO
Any complications from dental treatment or unpleasant experiences ? If Yes, please explain.
Bulimic/ anorexic?

No Past Present
Do you have any habits?

Smoking Hookah Soft Drinks Chew gum Suck Thumb or Finger Eat Candy Bite Nails Pipe Vape Smokeless tobacco
MEDICAL HISTORY
PHYSICIAN / SPECIALIST INFORAMTION

All questions marked with * must the answered.
Do you have a personal physician? *

Yes No
Physician's Name
Physician's Phone

Area Code Phone Number
Specialist's Name
Specialist's Phone

Area Code Phone Number
Date of Last Medical Checkup?
Are you being treated for any medical condition at the present or have you been treated within the past year? *

Yes No
If yes, please explain
Has there been any change in your general health in the past year? If yes, please explain. *

Yes No Not sure / Maybe
If yes, please explain
Are you taking any medications, non-prescribed drugs or herbal supplements of any kind? *

Yes No

Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list each one with Name, Dosage, Frequency.

	Name	Dose	Frequency	Condition treated
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Do you have allergies to - Indicate all that apply

Latex Codiene or other narcotics Penicillin or other antibiotics Sulfa Drugs Benzodiazepines ( Ativan, Halcion) Local Anesthetics Metals Food Animals Environment
If yes to any, please explain type of reaction.
Have you ever had a peculiar or adverse reaction to any medicines or injections? *

Yes No
If yes, please explain.
Do you have any artificial joints or implants? *

Yes No
If yes, please list along with date of surgery
Have you ever been advised by your doctor to take antibiotics before every dental treatment? *

Yes No
Please state name of the PreMedication or Antibiotic and last time it was prescribed for use prior to a dental appointment:
Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement? *

Yes NO
If yes, include date, type of replacement and any complications.
Provide orthopedic surgeon's name, number, clinic or hospital name.
Are you taking or planning to take an antiresorptive agent (such as Fosamax, Actonel, Boniva, Reclast, and Prolia)? Please indicate Date when taken last. *

Yes No
Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy? *

Yes No
If yes, please list
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? *

Yes No
If yes to any of the following Congenital Heart Defect (CHD) conditions, antibiotic prophylaxis is recommended. Please consult your physician.

Artificial (prosthetic) valve Previous infective endocarditis Damaged valves in transplanted heart CHD; unrepaired cyanotic CHD CHD; repaired completely in last 6 months CHD; repaired with residual defects
If you have cardiologist please provide Name, Address and Phone Number.
Have you ever had hepatitis, jaundice or liver disease? *

Yes No
Do you have or have you ever had any heart or blood pressure problems? *

Yes No
If yes, what was you most recent Blood Pressure reading
Do you have a bleeding problem or bleeding disorder? *

Yes No
Have you ever been hospitalized for any illnesses or operations? *

Yes No
If yes, please explain.

Do you have any of these conditions? Only check those that apply.

	Yes	No
Anemia
Angina / Chest Pain
Asthma
Cancer
Chemotherapy
Diabetes
Difficulty Breathing
Drug / Alcohol dependency
Frequent Headaches
Fainting
Glaucoma
Heart Attack
Heart Murmur
High Blood Pressure
Joint Replacement
Kidney Disease
lung disease
Mitral Valve Prolapse
Pace Maker
Radiation Therapy
Rheumatic Fever
Seizures
Stroke
Steroid Therapy
Stomach Ulcers
Thyroid Problems
Tuberculosis
Osteoporosis medications
HPV

Are there any conditions or diseases not listed above that you have or have had? If so what?
Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease). *

Yes No
Do you use tobacco, cannabis or vape? *

Yes No
If yes, please list type and frequency of use - We must be made aware if used prior to a dental appointment.
By Clicking "I ACCEPT" , i understand that if i use cannabis within 2 hours of my dental appointment, treatment will need to be rescheduled as i cannot legally provide consent. *

I ACCEPT
Are you nervous during dental treatment? *

Yes No Yes and i would like to discuss sedation options
If you are nervous, please explain ( sounds, needle, other)
How can we accommodate you better during your dental appoint,emt?
If you are pregnant or suspect you may be, how many weeks?
Are you taking birth control pills - Antibiotics can inhibit their affects. *

Yes No
Do you get cold sores / fever blisters? *

Yes No
I understand that if i have a cold sore on the day of an appointment, i should call ahead and ask if i will still be seen for my appointment. The virus can be transmitted to others or to other areas on myself. Therefore the appointment will be rescheduled. *

I understand
Do you have any disease, condition or problem that you feel we should know about? If so, please describe.
Obstructive Sleep Apnea Screening:

Untreated moderate to severe Obstructive Sleep Apnea has been associated with hypertension, heart attack, stroke, obesity, motor vehicle accidents, memory impairment, impotence, headaches as well as decreased quality of life.
Would you like to answer a few questions to be screened for potential Sleep Apnea? *

Yes No
Have you been told that you snore? *

Yes No
Are you tired during the day? *

Yes No
Has anyone observed you stop breathing while sleeping? *

Yes No
Do you have or are you being treated for High blood pressure? *

Yes No
BMI calculator (Enter weight in pounds and height in feet and inches)
Is your BMI more than 35 (Use calculator right above)?

Yes No
Is your age 50 years old or older? *

Yes No
Is your neck circumference greeter than 17" if male, or 16" if female?

Yes No
Is your gender male? *

Yes No
If you answered yes to 2 or more questions, it is very likley that you are at significant risk for obstructive sleep apnea.

If you answered yes to 3 or more questions, it is very likley that you have moderate to severe obstructive sleep apnea.
ADDITIONAL INFORMATION
Take Photo closeup of your smile. Teeth only. (optional)
PAYMENT
Will a child be unaccompanied to appointments? *

Yes No
Credit Card on file will be required at the first appointment. Unless the patient will have a credit card with parents approval.
APPOINTMENTS
Please be on time. We understand that patients are very busy, that their time is precious and that they do not like waiting. Orleans Gardens Dental Centre tries as much as possible to respect the time of their patients. Due to unforeseen emergencies, the waiting time may vary. Please arrive 5 minutes prior to your appointment. If you arrive late, this means that all the patients booked after you will have to wait. Therefore, if you arrive late, we will try to see you if time permits, otherwise the receptionist will offer you another appointment. *

I ACCEPT
In accordance with Privacy Legislation, for appointment scheduling/confirmation, you have my permission to speak with (spouse / partner etc...)

First Name Last Name
CANCELLATIONS AND NO SHOWS
Important! If you cannot come to your appointment, please call to let us know 48 business hours in advance. This allows us to see emergency patients and provide them with the care they need as opposed to just screening them when we have no time. Policy regarding no shows. We all forget sometimes, but if this becomes a recurring problem or if you fail to notify us, you will be charged $45 for the missed appointment. Please understand that we have emergencies daily and patients waiting for urgent care. *

I ACCEPT
EMERGENCY APPOINTMENTS
By clicking "I ACCEPT" , i understand that if an EMERGENCY appointment is booked, Orleans Gardens Dental Centre will evaluate, diagnose and prescribe medications if needed. We will do our best to provide treatment on the day of the emergency, but we cannot guarantee that it will be possible for each case. We have always been committed to seeing as many emergency patients as we can. *

I ACCEPT
GUARANTEES
No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results. *

I ACCEPT
PATIENT GENERAL CONSENT
Please Read and Accept by Signing at the end
Patient Consent and Medical / Dental History I, the undersigned, certify that I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code, and I can ask to see the Code at any time. I agree that Orleans Gardens Dental Centre can collect, use and disclose personal information about me (patient / guardian requesting service in email) as set out above in the information about the office’s privacy policies. I also certify that I have provided and accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the 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 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 the payment of the dental services for myself and my dependants is mine, and I assume responsibility for fees associated with these services. *

Clear
Patient / Parent / Guardian *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty:

PATIENT INTAKE QUESTIONNAIRE

PREVIOUS DENTIST / OFFICE INFORMATION:

Insurance - Primary

Insurance - Secondary

IN CASE OF EMERGENCY:

DENTAL SPECIALIST INFORMATION:

DENTAL HISTORY:

MEDICAL HISTORY

PHYSICIAN / SPECIALIST INFORAMTION

Obstructive Sleep Apnea Screening:

ADDITIONAL INFORMATION

PAYMENT

APPOINTMENTS

CANCELLATIONS AND NO SHOWS

EMERGENCY APPOINTMENTS

GUARANTEES

PATIENT GENERAL CONSENT