905-457-4445

info@sterlingdentistry.ca

"For a Lifetime of Smiles"

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    Patient Information    
A parent or guardain will be responsible for decisions on my treatment: Yes No
  Name   DOB  
  Gender Male Female   Address  
  Contact No        
  Name of Employer :   Email  
  Address of Employer :   Emergency Contact :  
  Family Doctor :   Contact No  

    Financial Information    
Method of Payment : Cash Credit Insurance Other
  Person responsible for Financial matters : Self Spouse Parent/Gurdain Other  
  Name   Address  
  DOB   Contact No  
  Office No        
  Ins. Company :   Employer/Policy Holder :  
  Tel:   Ins. Yr. end :  
             
    PRIMARY INSURANCE    
  Policy# :   Certificate#  
  ID/SIN# :   Max Cov :  
  % coverage for :   Basic  
  Maj. Restorative :        
  Ins. Company :   Employer/Policy Holder :  
  Tel   Ins. Yr. end :  
    SECONDARY INSURANCE    
  Policy# :   Certificate#  
  ID/SIN# :   Max Cov :  
  % coverage for :   Basic  
  Maj. Restorative :        
             

    Medical History (This information will remain confidential)    
Q 1 Are you presently under the care of a physician? : Yes No   Explain :
Q 2 Have you ever been hospitalized ? : Yes No   Explain :  
Q 3 Are you taking any drugs or medication at this time? : Yes No  
A
B
C
Q 4 Have you ever had any adverse effect to any of the following ? :
Antibiotic : Penicilin Sulfonamide Other
Barbiturates (Sleeping Pills) Codeine Darvon Local Anaesthetic None
Q 5 Have you ever been warned against using any medications ? Yes No   Which :  
Q 6 Have you ever taken prolonged medical or non-medical drugs? : Yes No   Which :  
Q 7 Do you suffer from any allergies(hay fever,latex fever etc.) ? : Yes No   Which :  
Q 8 Do you bruise easily or having prolonged bleeding? : Yes No        
Q 9 Do you smoke ? : Yes No   How much per day? :  
Q 10 Have you ever fainted, had shortness of breath or chest pain ? : Yes No        
Q 11. Women Are you pregnant ? : Yes No Using birth control ? : Yes No  
    Reached menopause ? Yes No      
Q 12 CHILDREN Have you recently had any of the following (approximate date?) Chicken pox Measles Mumps  
Q 13 Do you have or Have you ever had any of the following? :    
 
A.I.D.S Cancer Heart disease/attack   Jaundice
Anemia Circulation problems     Kidney disease
Angina pectories Congenital heart lesions Heart pacemaker/surgery Liver disease
Anorexia nervosa     Heart rhythm disorder Leukemia
Artificial Heart valve Diabetes Hepatities A/B/C Lung disease
Artificial joints (hips, Knees) Drug/alcohol dependence Herpes Malignant hypothermia
Asthma Emphysema High /Low Blood pressure Mental/nervous disorder
Blood disorders Epilepsy H.I.V Positive Mitral valve prolapse
Bronchities Glandular disorders Hodgkin disease Organ transplant
    Glaucoma Hyper (Hypo) Glycemia Psychiatric disorders
    Head / Neck injuries Hypertension Radiation / Chemotherapy

    Dental History    
What is the reason for today's visit ? : Emergency Regular Other   If other, explain
  How frequently do you see a dentist ? : 3-6 months Annually Other If other, explain  
  When was your last dental visit ? :   Last X-Ray?  
  How often do you brush per day ? :   Floss? :  
  Are your teeth sensitive to : Cold Sweets Heat Other  
  Do your gums bleed when : Brushing Flossing Never  
  Do your gums feel swollen or tender ? : Yes No   Do you have a bad breath or a bad taste in your mouth ? : Yes No  
  Do your jaws crack, pop or grate when you open widely? :: Yes No   Do you grind or clench your teeth ? : Yes No  
  Do you have food catch between your teeth? : Yes No   Have you ever bad local anesthetic(freezing) ? Any complications? : Yes No  
  Have you ever had any of the following ? : Bridgework Crowns & Caps Full or Partial Dentures Orthodontic(braces) Periodontal Treatment (Gums) Root Canal  
  Are you satisfied with your teeth ? :        
 
  GENERAL RELEASE : I, undersigned, understand that the information contained in the medical and dental history is important to my treatment , I certify that all of the information I have completed is correct and that I have not knowingly omitted data. I conset to the release of medical information from my medical doctor or the other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment.I understand that it is my responsibility to pay for the dental treatment for both myself and my dependents.I assume all resposibility for fees associated with my dental treatment or dental diagnostic procedures.  
  Signature :          
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