Willowdale Endodontics (Downtown Core)   d Back to Forms

Patient Registration, Health History & Office Policies

181 University Ave, Ground Floor, Toronto, ON M5H 3M7      416-368-4500

The information in this questionnaire is CONFIDENTIAL and enables our office to provide the highest level of care and service possible. Please complete all forms as completely as possible. Thank you.

Patient Information

First Name:
Last Name:
E-mail:
Date of Birth:
Home Phone #:
Cell #:
Sex at Birth:

Address:
City:
Province:
Postal Code:
Person responsible for account: Self / Other
Do you have a dental plan?

Insurance Company (Primary):
Group Policy/Plan Number:
Certificate / ID #:
Ins. Policy Holder Name:
Policy Holder D.O.B.:
Insurance Company (Secondary):
Group Policy/Plan Number:
Certificate / ID #:
Ins. Policy Holder Name:
Policy Holder D.O.B.:
Employer:
Occupation:
Referring Dentist:
Family Physician:
Phone Number:
Emergency Contact:
Relationship:
Telephone:

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. Please fill in the entire form.

Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain?

If yes, explain
Has there been any change in your general health in the past year?

If yes, explain
Are you currently taking any medication, non-prescription drugs or herbal supplements of any kind?

If yes, please specify
Do you have any allergies? (e.g. penicillin, latex/rubber product)

If yes, please specify
Have you ever had a peculiar or adverse reaction to any medicines or injections?

If yes, please explain
Do you have a heart problem of any kind?

If yes, please explain
Are you required to take a pre-med antibiotic prior to ALL DENTAL TREATMENT?

Have you ever had hepatitis, jaundice or liver disease?

Women only: Are you:

Have you ever been hospitalized for any illness or operations?

If yes, please explain

Do you have or have you ever had any of the following? Please check those that apply.

YesNo YesNo
Aids/HIV Anemia
Asthma Arthritis
Rheumatism Blood Disease
Cancer Diabetes
Dizziness Hip Replacement Surgery
Epilepsy Seizures
Knee Replacement Bleed or Bruise Easily
Excessive Bleeding Kidney Disease
Fainting Liver Disease
Lung Disease Head Injuries
Mental Illness Depression
Chronic Anxiety High Blood Pressure
Tuberculosis Low Blood Pressure
Heart Murmur Osteoporosis Medications (e.g. Fosamax, Actonel)
Mitral Valve Prolapse Rheumatic Fever
Prosthetic Heart Valve Stomach Ulcer
Stroke TIA Thyroid Problem
Venereal Disease Drug / Alcohol Use or Dependency
Have you ever had any illness not included above?

If yes, please specify
Are you nervous during dental treatment?

If yes, please specify
How important is keeping your natural teeth? (10 being VERY IMPORTANT)

Office Policy (Please Read)

I, being the patient or parent/guardian of the above minor patient, understand that the information contained in the medical history is important to my dental treatment. I certify that all the information I have completed is correct and I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other healthcare providers as is required by this dental office to perform diagnostic procedures as required to determine necessary treatment.

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