PERIOPARTNERS MEDICAL HISTORY QUESTIONNAIRE

Name:*

First NameLast Name

Date of Birth:*

Date

Phone Number (Home):

Phone Number (Cell):

Address:*

Street Address

Street Address Line 2

CityProvince

Postal Code

Email:*

example@example.com

Address (Business):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number (Business):

Please enter a valid phone number.

Occupation:

Who referred you to our office?:*

Contact Name:

Relationship:

Phone Number:

Please enter a valid phone number.

Name of Family Doctor:

Doctor Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Doctor Phone:

Please enter a valid phone number.

(1) Name of Medical Specialist:

Area of Specialty:

Phone:

Please enter a valid phone number.

(2) Name of Medical Specialist:

Area of Specialty:

Phone:

Please enter a valid phone number.

Insurance Carrier:

Policy Holder:

Date of Birth:

Date

Group/Plan No:

Cert No/ID No:

Secondary Insurance Carrier:

Policy Holder:

Date of Birth:

Date

Group/Plan No:

Cert No/ID No:

1. In the event of a needle stick or puncture wound to our staff during your dental treatment do you consent to a laboratory blood test for any blood-borne communicable diseases?*

YesNo

2. Who is your general dentist?*

3. How long have you been seeing your general dentist?*

4. How often do you see your general dentist and/or hygienist for checkups and cleanings?*

5. When was your last cleaning?*

6. Do you know why you were referred to our office?*

7. How many times per day do you brush your teeth? *

7b. Do you use a manual or an electric toothbrush?*

8. How many times per day do you floss your teeth?*

9. Do you use any other dental hygiene tools at home? For example: waterpik, interproximal brush etc.*

10. How would you rate your overall dental health? On a scale of 1-10 where 1 is the worst and 10 is the best.*

11. Have you noticed any areas of gum recession in your mouth?*

YesNoNot sure/maybe

11b. If yes, does this bother you from an esthetic or sensitivity standpoint?

12. How would you rank your current overall daily stress levels?*

LowMediumHigh

13. Do you have any teeth that are loose or painful?*

YesNoNot sure/maybe

14. Have you ever been diagnosed with diabetes?*

YesNoNot sure/maybe

14b. If yes, do you know your more recent HbA1c value?

15a. Do you smoke? (tobacco or marijuana)*

YesNo

15b. Do you Vape?*

YesNo

15c. Do you chew tobacco?*

YesNo

15d. If you smoke, vape or use chewing tobacco, are you interested in quitting?

16. Are you nervous during dental treatment?*

YesNoNot sure/maybe

16b. Would you be interested in discussing sedation modalities for treatment when possible?*

YesNoNot sure/maybe

17. Are you being treated for any medical condition at the present or have you been treated within the past year?*

YesNoNot sure/maybe

17b. If so, why?

18. When was your last medical check-up?*

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

YesNoNot sure/maybe

19b. If yes, please explain:

20. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

YesNoNot sure/maybe

20b. If yes, please list:

21. Do you have any allergies? For example: Medications, latex, rubber products, hay fever, foods.*

YesNoNot sure/maybe

21b. If yes, please list:*

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

YesNoNot sure/maybe

22b. If yes, please explain:*

23. Do you have asthma or do you use an inhaler daily?*

YesNoNot sure/maybe

24. Do you have or have you ever had any heart or blood pressure problems?*

YesNoNot sure/maybe

24b. If yes, please list:

25. Do you have any joint replacements?*

YesNoNot sure/maybe

25b. If yes, please list and on what date:

26. Do you have any conditions or therapies that could affect your immune system? For example: leukemia, AIDS, HIV infection, radiotherapy, chemotherapy*

YesNoNot sure/maybe

26b. If yes, please list:

27. Have you ever had hepatitis, jaundice or liver disease?*

YesNoNot sure/maybe

27b. If yes, please list:

28. Do you have a bleeding problem or bleeding disorder?*

YesNoNot sure/maybe

28b. If yes, please list:

29. Do you have or have you ever had any of the following? Please check.

30. Are there any conditions or diseases not listed above that you have or have had?*

YesNoNot sure/maybe

30b. If yes, please list:

31. Are there any diseases or medical problems that run in your family? For example: diabetes, cancer or heart disease)*

YesNoNot sure/maybe

31b. If yes, please list:

32. For women only: Are you breast-feeding or pregnant?

YesNoNot sure/maybe

32b. What is the expected delivery date?

33. We generally discuss our patient’s dental treatment at our reception area. Would you prefer a more private area?*

YesNoNot sure/maybe

I Certify that I have read, and I understand the questions above. I acknowledge that my questions, if any, about the inquiries above have been answered to my satisfaction. I will not hold my doctor, affiliated entities, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

Please use your mouse or finger to sign below.*

(Signature)

Date:*

Date

We are committed to protecting the privacy of your personal information and using all personal information in a responsible and professional manner.

PERSONAL INFORMATION COLLECTED
• Names, residence and business addresses, email addresses, cell, residence and business telephone numbers.
• Financial information such as dental insurance information, third party dental provider information and payment transaction slips if you are paying by credit or debit card.
• Pertinent medical and dental histories and clinical photographs.

HOW WE USE THE INFORMATION COLLECTED
Personal information is used to open and update patient files, to contact patients for follow-up treatment, process dental benefit claims and to send patients informational material about our practice.

Financial information is used to process payments for our services, to process claims for third party providers and dental insurance companies and collect unpaid accounts.

Medical and dental information is used to diagnose and safely and appropriately treat dental conditions.

WHOM WE MIGHT DISCLOSE PERSONAL INFORMATION TO
Insurance companies and third party dental providers for approval, re-imbursement or payment of dental services.

To other dentists, dental offices or health professionals where we are seeking a second opinion and the patient has consented to obtaining a second opinion or where we are referring the patient for diagnosis and treatment.

To other dentists, dental offices or health professionals who have asked us, with the consent of the patient, for a second opinion or who have referred the patient to our office for diagnosis and treatment.

To legal firms or other parties with the consent of the patient. To the Alberta Dental Association and College, the regulatory board of dentists, who may inspect our records and interview our staff as part of its regulatory activities in the public interest.

If we consider selling all or part of our dental practice the potential qualified purchaser may be granted access to patient information as part of the due diligence process to verify information necessary for the potential sale. If this occurs we will take steps to ensure the non-disclosure of your personal information.

I consent to the collection, use and disclosure of my personal information as indicated above.

Date:*

Date

Print Name:*

First NameLast Name

Please use your mouse or finger to sign below.*

(Signature)

It is the practice of our office to see all our patients on an appointment basis. We respect your time and make every effort to remain on schedule. We ask that you extend the same courtesy to us. If you are unable to keep your appointment, we request that you notify us at least 1 week prior to your appointment. Patients who fail to provide us with one-week cancellation notification time may be charged a missed appointment fee of $250.

If you have any questions or require clarification, please contact our office.

I have read and understood the Cancellation Policy as outlined herein. I agree to the terms described and assume full liability for any fees charged should I fail to abide by these short notice requirements.

Date:*

Date

Please use your mouse or finger to sign below.*

(Signature)

MEDICAL HISTORY QUESTIONNAIRE

CONTACT INFORMATION

IN CASE OF EMERGENCY

INSURANCE INFORMATION

QUESTIONNAIRE

PERSONAL INFORMATION CONSENT FORM

PATIENT ACKNOWLEDGEMENTS