Patient Intake Form

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TS Dental Patient Intake Form

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- Step 1 of 4

Prefix *

Other Gender

Marital Status *

Gender *

Name *

First

Last

Preferred Name

Date of Birth *

Day

. *

Month

. *

Format: YYYY (example: 1998)

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Home Phone

Cell Phone

Email *

Employer / School

Occupation

Family Physician

Physician Phone Number

Emergency Contact Information

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Patient Referral

Your referral information is valuable, as it assists us in improving our outreach efforts

Referral: Please select all that apply

Patient
Friend
Doctor
Staff Member
Flyer
Google Reviews
Google Search
TS Dental Website
Facebook Ad
TS Dental Facebook Page
Facebook Group
RateMD Reviews
Other

Please specify

Medical History

Have you ever had a serious ilness, requiring hospitalization or extensive medical care? *

Please explain

Are you presently under the care of a physician? *

Please explain

Do you use any prescription or non prescription drugs regularly? *

Please explain

Do you have any allergic conditions: e.g. hay fever, skin rash, food allergies, metal, latex? *

Please exaplain

Do any allergic reactions result in headaches, shortness of breath, chest constrictions, nausea? *

Please explain

Have you ever experienced any unusual reaction to any of the following *

Local Anesthesia
Aspirin
Penicillin
Codeine
Sulpha Drugs
Barbiturates (sleeping pills)
Any other medicine (Explain below)
None

Please explain

Have you been hospitalized in the last 5 years? *

Please explain

Have you been warned against taking any drug or medication? *

Please explain *

Do you bruise easily or bleed abnormally? *

Have you ever had any organ implants or medical implants? *

Please explain *

Have you ever fainted? *

Please provide more details *

Do you experience shortness of breath or chest pain when walking or climbing stairs? *

Do you have any of the following conditions? Please check any that apply: *

Heart Murmur or Mitral valve Prolapse
Stomach/Intestinal Problems/Ulcers
Joint Replacement
Mental or Nervous disorder
High/low blood pressure
Hyper/Hypo Glycemia
Epilepsy or Seizures
Cortisone/Steroid Therapy
Malignant Hyperthermia
Drug/Alcohol Dependency
Hepatitis A/B/C
Lung Disease
Thyroid Disease
Arthritis or Rheumatism
Scarlet or Rheumatic Fever
Cancer/Chemotherapy
Emphysema
Diabetes
Kidney Problems
Cold Sores
Heart Attack
Sinus Trouble
Tuberculosis
Liver Disease
Stroke
Herpes
Jaundice
AIDS/HIV
Glaucoma
Other - Please explain in the line below
None
Choice 35

Have you had any injury, surgery or x-ray therapy to your face or jaws? *

Please explain *

Do you have any disease, condition or problem that you think the doctor should know about? *

Please explain

Are you pregnant or suspect you might be? If so What month are you in? *

How many months pregant

Are you taking birth control pills? *

Are you nursing? *

Dental History

Reason for your visit: *

Exam
Cleaning
Emergency
Other

If you selected "Other", please provide the reason for your visit

Are you presently having dental pain? *

Please explain *

Is there a dental problem you would like to take care as soon as possible? *

Please explain

How frequently you see your dentist? *

3-6 Month
6-12 Months
Annualy
Rarely
Never

When was your last cleaning? *

When was your last dental visit? *

Does food get caught between your teeth? *

Have you had any of the following: *

Braces
Oral Surgery
Gum Treatment
Root Canal
None

Are your teeth sensitive to any of the following: *

Hot
Cold
Biting
Sweets
None

Do you grind or clench your teeth during the day or night? *

Do you smoke or vape? *

How much?

Have you ever experienced any growth or sore spots in your mouth? *

Where?

Previous problems with dental treatment? *

Please explain

Are you nervous about dental appointments? *

How can we make your visit more comfortable? *

Have you ever experienced complications during dental appointments? *

Please explain *

Do you have any missing teeth? *

Would you like to learn about dental implants to replace missing teeth? *

Have you experienced gum recession on any of your teeth? *

How often you brush your teeth? *

How often you floss? *

Do you feel you have bad breath at times? *

Do your gums feel swollen or tender? *

Do your gums bleed easily? *

Do your teeth feel rough (not smooth)? *

Have you ever been given oral hygiene instruction? *

Do your teeth stain easily? *

Are your teeth sensitive during brushing? *

General Release / Patient Consent

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 the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary.

Name *

First

Last

Signature *

Clear Signature

Select One of the Following *

Signing for Self
Signing as Parent
Signing as Guardian

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13085 Yonge St Unit #15
Richmond Hill, ON L4E 3S8
905-313-1003

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