Medical History - TechTown Dentistry

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Medical History Form

We need this information to ensure your safety and health and the best possible dental care for you. All information is kept confidential among our team members, your emergency contacts, and, if necessary, your doctor. Please fill in the fields below and click "submit". By submitting this form you agree that you:

have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information
have had the opportunity to ask questions and receive answers about your medical-dental history
authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care
understand that consultation with your medical doctor may be required, and you consent to your physician being contacted if necessary
understand that responsibility for payment for the dental services provided for you or your dependents is yours, and you will assume responsibility for fees associated with these services.

* Abbreviation

Mr. Mrs. Miss Ms. Dr. Mx.

* Name

Gender

Male Female Transgender Non-binary Prefer not to respond Prefer to self-describe below

(Gender) Please specify

Home Phone

Work Phone

Cell Phone

* Email Address

Preferred method of contact

Phone call Text Message Email

* Date of Birth (MM/DD/YYYY)

* Address (Please include city + postal code)

Whom may we thank for referring you?

In Case of Emergency

(In case of Emergency) Name of Emergency Contact

(In case of Emergency) Relationship to Patient

(In case of Emergency) Phone number

Responsibility for your Account

Do you have dental insurance? (Please bring this information with you to the office)

Yes No

(Responsibility) Name of person responsible for your account, if not yourself

(Responsibility) Relationship of the Insured Party, if not yourself

(Responsibility) Where do you or the insured party work?

Your Medical History

1. Are you presently under the care of a physician? If yes, fill out reason below

Yes No

(Under care of a physician) Reason

2. Are you currently taking any medications? If yes, please list below

Yes No

List of medications

3. Have you been hospitalized in the last 5 years? If yes, please enter reason below

Yes No

Reason for hospitalization

4. Have you ever been prescribed antibiotic coverage before a dental appointment?

Yes No

5. Are you allergic to any medications? If yes, please list below

Yes No

(Medication Allergies) List

Do you smoke? If yes, please enter how many per day below.

Yes No

(Do you smoke) Times per day

7. (Women Only) Are you pregnant or suspect you might be?

Yes No

8. (Women Only) Are you taking birth control pills?

Yes No

9. (Women Only) Are you taking supplementary hormones?

Yes No

10. Have you gained or lost more then 10 pounds in the last year?

Yes No

11. Would you say your diet is adequate and balanced?

Yes No

12. Do you consume alcohol? If yes, please enter drinks per day / drinks per week below.

Yes No

(Alcohol) Drinks per day

(Alcohol) Drinks per week

14. Do you use cannabis for recreational or medical purposes? If yes, please enter the medical condition below.

Yes No

(Cannabis) Medical condition

Check all conditions that apply to your medical history

List Medical Condition

Physician Details

Physician's Name

Physician's Phone Number

Physician's Address

Your Dental History

Date of last dental visit

Treatment you received

Date of last X-rays

How often do you brush?

How often do you floss?

Do you use other hygiene aids?

Check all that apply to your dental history

Your bite

Do you grind or clench your teeth?

Yes No

Have you noticed chipped or worn edges on your teeth?

Yes No

Has a dentist adjusted the way your teeth fit together?

Yes No

Do you awaken with headaches?

Yes No

Is it difficult to open or close your jaw?

Yes No

Do you hear clicking/popping sounds when chewing?

Yes No

Your gums

Are your gums swollen or tender?

Yes No

Do you experience bad breath?

Yes No

Do your gums bleed when you eat, brush, or floss?

Yes No

Are there any sore spots in your mouth?

Yes No

Are you aware of any loose teeth?

Yes No

Are any teeth sensitive to heat, cold, sweets, pressure?

Yes No

ADDRESS:
180 Northfield Dr. West
Waterloo, ON N2L 0C7

Phone: (519)-746-7333

Email: [email protected]