Medical Questionnaire Form Online at Quad Dental

Adult Patient

Occupation

Marital Status

M S D W

Employer

Phone (work)

Insurance Company

Plan Number

ID Number

Whom may we thank for referring you?

DENTAL HISTORY

(Please check YES/NO to each question. If you’re unsure how to answer, please consult our staff!)

Is there a dental problem you would like treated immediately? Yes No

Do you have dental anxiety? If yes, please explain below.

Reason for today’s visit?

Date of your last dental visit?

Last dental cleaning?

Last x-rays?

1. Are you having regular dental visits?

Yes No

2. Have you ever had any of the following?

Yes No

Periodontal Treatment (treatment of gums)?

Orthodontic Treatment (to straighten or realign teeth)?

A bite plate or any other appliance?

Your bite adjusted or teeth ground?

Oral Surgery (surgery in or about the mouth/jaw joint, or implant surgery in one or both of your jaw joints)?

3. Do you feel you have bad breath?

Yes No

How often do you brush your teeth?

4. Do you use dental floss, proxabrush, stimudents or any other interproximal tools?

Yes No

5. Do your gums bleed when brushing or eating, or, do you suffer from pain or swelling of your gums?

Yes No

6. Are any of your teeth sensitive to heat, cold, sweets or pressure?

Yes No

7. Have you ever experienced any of the following jaw problems?

Yes No

Popping/clicking in your jaw joints?

Pain in your jaw joints, around your ear, or side of your face?

Difficulty in opening or closing?

Pain when teeth are clenched?

Pain or difficulty when chewing?

8. Do you have any of the following habits?

Yes No

Clenching or grinding your teeth while awake or asleep?

Biting your cheeks or lips?

Mouth breathing while awake or asleep?

Placing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)?

1. Are you being treated for any medical condition at present or within the past year? If yes, please explain.

Yes No

2. Has there been any changes in your general health in the past year?

Yes No

3. List any PRESCRIPTION or NON-PRESCRIPTION drugs you are taking or have recently taken (including birth control pills):

4. Have you ever had any adverse or unusual reaction to any medications or injections? (e.g. penicillin, or other antibiotics, aspirin, codeine, local anesthetic ("dental freezing")? If yes, please explain.

Yes No

5. Have you ever been advised against taking any specific type of medication?

Yes No

6. Do you have any allergies (e.g. hay fever, food allergies, latex/rubber or metal allergies)?

Yes No

7. Have you ever fainted during dental or medical treatment?

Yes No

8. Do you bleed excessively from a cut or injury, bruise easily or have any blood disorders? If yes, please explain.

Yes No

9. Do you have any artificial joints (e.g. hip, knee)?

Yes No

10. Indicate which of the following you presently have, or ever had: (Please check all that apply)

Asthma

Epilepsy or Seizures

Tuberculosis

Glandular Disorders

Bronchitis

Hepatitis

Diabetes

Organ Transplant/Medical Implant

Emphysema

Jaundice

Kidney Disease

Stomach/Intestinal Problems

Lung Disease

Liver Disease

Thyroid Disease

Ulcers

11. Is there anything else about your health we should be made aware of; or do you wish to speak to the doctor privately about any problem or medical condition?

Yes No

12.WOMEN ONLY : Are you pregnant? If so, when is your delivery date?

13. Are you breast feeding?

Yes No

PERMISSION TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION

Our office understands the importance of protecting your personal information.

We will collect, use and disclose your personal information only for appropriate purposes:

To diagnose and provide health care.
To communicate with you and your other health care professionals.
For scheduling and billing purposes, including completion of dental claim forms
To comply with the legal requirements of the RCDS of Ontario, provincial regulations, and to generally comply with the law.
For audit and evaluation of the dental practice.
To provide and invoice, process credit or debit card payments, and to collect unpaid accounts.
If at any time the practice were to transfer ownership for the purpose of uninterrupted care, to transfer your full patient information file.

If a new purpose would arise for the use and disclosure of your personal information, we will seek your approval in advance. We will not under any conditions supply your insurer with your confidential medical history, without your specific consent. If unusual requests are received, we will contact you for permission prior to releasing such information. You many withdraw your consent for use of disclosure of your personal information, and we will explain the ramifications of that decision. In this office, any Doctor may act as the Privacy Information Officer. Do not hesitate to discuss our policies with any member of our office staff.

I have reviewed the above information that explains how our office will use my personal information, and the steps taken 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 authorize the QUAD Dental staff and associates to take intra-oral photographs before, during, and after treatment to be used for patient education, and social media marketing. I understand that my identity will remain confidential when photos are used for such purposes.

I consent to my photos being used for the reasons stated above. I do not consent to my photos being used for the reasons stated above.

I agree that Quad Dental can collect, use and disclose personal information about me as set in the above privacy policies.

GENERAL RELEASE

I, the undersigned, certify that I have provided an 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. Should there be any change in my health status in the future, I will advise this dental office. 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 payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.

Print Name or Name of Guardian

Date

Witness

Draw Signature

Signed by: Patient Parent Guardian

Welcome to QUAD Dental

NEW PATIENT FORM

DENTAL HISTORY

MEDICAL HISTORY

PERMISSION TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION

GENERAL RELEASE

Opening Hours