West Ridge Family Dentistry

ATTENTION: The following information is required to enable us to provide you with the best possible dental care. All information collected is strictly confidential and is protected by doctor-patient confidentiality in accordance with the Personal Information Protection Act 2004. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

Personal Information

First Name *

Last Name *

Date of Birth (dd/mm/yy) *

E-mail *

Telephone *

Alternate Telephone

How did you hear about us? *

Current Pharmacy

Home Details

Street Address

City

Postal Code

Business Details

Street Address

City

Postal Code

Business Telephone

Occupation

Emergency Contacts

Name *

Telephone *

Relationship

Family Doctor

Doctor’s Phone Number

Doctor’s Address

Complete and explain if necessary

1. Are you having any discomfort at this time?

2. Do you feel very nervous about having dental treatment?

3. Have you ever had any problems with anesthetic?

4. Has anyone related to you ever had problems with anesthetic?

5. Do you or any of your relatives have malignant hyperthermia?

6. Do you wear a medic alert bracelet?

7. Are you under treatment by your physician?

8. Do you smoke?

9. Do you drink alcohol, wine or beer? If so, how much per week?

10. Do you use recreational drugs? If so please list which kind(s).

11. Do you have dentures, caps or bridgework?

12. Do you have any loose teeth?

13. Do you have any problems opening your mouth fully?

14. Have you taken any steroids (i.e. cortisone or prednisone) in the last 12 months?

15. Do you take pills that thin your blood?

16. Have you ever had a blood transfusion?

17. When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath or because you are very tired?

18. Do you ever have difficulty breathing even without exerting yourself?

19. Does shortness of breath or other breathing problems ever wake you up at night?

20. Have you ever used puffers for your breathing?

21. Do you wear contact lenses?

22. Do you take antibiotics prior to dental work or surgery?

23. Have you ever had any excessive bleeding requiring special treatment?

24. Do you have a confirmed latex allergy?

25. Do you have hives, itchy rash or swelling after contact with rubber products? (i.e. latex gloves, balloons, condoms, rubber mouth dams (from dentist))

26. Are you allergic to bananas, kiwi, water chestnuts or avocados?

27. Do you have any other allergies? (ie. hayflower, pollen)

28. Women - Could you be pregnant?

Have you had, or do you have:

1. Rheumatic or scarlet fever, heart valve problems or replacement, heart murmur, congenital heart disease, heart problems?

2. Heart attack, angina?

3. High or low blood pressure?

4. Heart failure, irregular heart beat, other heart conditions or surgery?

5. Chest pain, shortness of breath, ankle swelling?

6. Blood clots (phlebitis)?

7. Stroke or transient stroke (TIA)?

8. Artificial joint replacement (hip, knee)?

9. Asthma, bronchitis, emphysema, pneumonia, tuberculosis (TB), chronic cough, pneumonia, sinus trouble?

10. Seizure, fainting spells, or blackouts?

11. Nervousness, frequent headaches?

12. Gastrointestinal disease, ulcers, colitis, rectal bleeding, hiatus hernia/reflux?

13. Hepatitis A/B/C, liver disease, yellow jaundice?

14. Anemia (thin blood), sickle cell disease or other blood disorders?

15. Nose bleeds, easy bruising, hemophilia or other bleeding abnormality?

16. Diabetes, thyroid, kidney or adrenal disease?

17. Epilepsy or seizures?

18. Glaucoma or eye problems?

19. Arthritis, rheumatism, muscular dystrophy or other muscular disorders?

20. Venereal disease (Syphilis, Gonorrhea, Genital Herpes)?

21. Immunologic problems?

22. Cancer, chemotherapy, radiation?

23. Alcohol or drug abuse; psychiatric treatment?

24. Sleep apnea?

Miscellaneous Items

Drug Allergies

Medications

Previous Surgeries

Do you have any disease, condition or problem listed above that the Dentist should know about?

Form Completed By

Clear Form

If a response is not received within your desired timeframe, please call us at (705) 329-1600.



	ATTENTION: The following information is required to enable us to provide you with the best possible dental care. All information collected is strictly confidential and is protected by doctor-patient confidentiality in accordance with the Personal Information Protection Act 2004. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form. All fields marked with an * are required. Personal Information First Name * Last Name * Date of Birth (dd/mm/yy) * E-mail * Telephone * Alternate Telephone How did you hear about us? * Current Pharmacy Home Details Street Address City Postal Code Business Details Street Address City Postal Code Business Telephone Occupation Emergency Contacts Name * Telephone * Relationship Family Doctor Doctor’s Phone Number Doctor’s Address Complete and explain if necessary 1. Are you having any discomfort at this time? 2. Do you feel very nervous about having dental treatment? 3. Have you ever had any problems with anesthetic? 4. Has anyone related to you ever had problems with anesthetic? 5. Do you or any of your relatives have malignant hyperthermia? 6. Do you wear a medic alert bracelet? 7. Are you under treatment by your physician? 8. Do you smoke? 9. Do you drink alcohol, wine or beer? If so, how much per week? 10. Do you use recreational drugs? If so please list which kind(s). 11. Do you have dentures, caps or bridgework? 12. Do you have any loose teeth? 13. Do you have any problems opening your mouth fully? 14. Have you taken any steroids (i.e. cortisone or prednisone) in the last 12 months? 15. Do you take pills that thin your blood? 16. Have you ever had a blood transfusion? 17. When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath or because you are very tired? 18. Do you ever have difficulty breathing even without exerting yourself? 19. Does shortness of breath or other breathing problems ever wake you up at night? 20. Have you ever used puffers for your breathing? 21. Do you wear contact lenses? 22. Do you take antibiotics prior to dental work or surgery? 23. Have you ever had any excessive bleeding requiring special treatment? 24. Do you have a confirmed latex allergy? 25. Do you have hives, itchy rash or swelling after contact with rubber products? (i.e. latex gloves, balloons, condoms, rubber mouth dams (from dentist)) 26. Are you allergic to bananas, kiwi, water chestnuts or avocados? 27. Do you have any other allergies? (ie. hayflower, pollen) 28. Women - Could you be pregnant? Have you had, or do you have: 1. Rheumatic or scarlet fever, heart valve problems or replacement, heart murmur, congenital heart disease, heart problems? 2. Heart attack, angina? 3. High or low blood pressure? 4. Heart failure, irregular heart beat, other heart conditions or surgery? 5. Chest pain, shortness of breath, ankle swelling? 6. Blood clots (phlebitis)? 7. Stroke or transient stroke (TIA)? 8. Artificial joint replacement (hip, knee)? 9. Asthma, bronchitis, emphysema, pneumonia, tuberculosis (TB), chronic cough, pneumonia, sinus trouble? 10. Seizure, fainting spells, or blackouts? 11. Nervousness, frequent headaches? 12. Gastrointestinal disease, ulcers, colitis, rectal bleeding, hiatus hernia/reflux? 13. Hepatitis A/B/C, liver disease, yellow jaundice? 14. Anemia (thin blood), sickle cell disease or other blood disorders? 15. Nose bleeds, easy bruising, hemophilia or other bleeding abnormality? 16. Diabetes, thyroid, kidney or adrenal disease? 17. Epilepsy or seizures? 18. Glaucoma or eye problems? 19. Arthritis, rheumatism, muscular dystrophy or other muscular disorders? 20. Venereal disease (Syphilis, Gonorrhea, Genital Herpes)? 21. Immunologic problems? 22. Cancer, chemotherapy, radiation? 23. Alcohol or drug abuse; psychiatric treatment? 24. Sleep apnea? Miscellaneous Items Drug Allergies Medications Previous Surgeries Do you have any disease, condition or problem listed above that the Dentist should know about? Form Completed By Clear Form If a response is not received within your desired timeframe, please call us at (705) 329-1600.





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