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Meet Us
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- Covid-19 Wellness Screening Form
- Medical History Form
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info@dentistryonwellington.com

Patient Form

It would be our pleasure

* INDICATES REQUIRED FIELD

MEDICAL ALERT:

NAME: MR./MISS/MRS./MS./DR *

DATE OF BIRTH (DAY/MONTH/YEAR) *

ADDRESS (HOME)

PHONE *

ADDRESS (BUSINESS)

OCCUPATION *

WHO REFERRED YOU TO OUR OFFICE?

EMAIL *

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

NAME *

RELATIONSHIP *

DAY-TIME PHONE *

NAME OF THE FAMILY DOCTOR

PHONE OR ADDRESS

(1) NAME OF MEDICAL SPECIALIST

AREA OF SPECIALITY

PHONE OR ADDRESS

(2) NAME OF MEDICAL SPECIALIST:

AREA OF SPECIALITY

PHONE OR ADDRESS

The following information is required to enable us to provide you with the best possible dental care.

All information is stricly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

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

Yes
No
Not Sure/Maybe

Optional:

2. When was your last medical checkup? *

Yes
No
Not Sure/Maybe

Optional:

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

Yes
No
Not Sure/Maybe

Optional:

4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list them. *

Yes
No
Not Sure/Maybe

Optional:

5. Do you have any allergies? If yes, please list them using the categories below: *

Yes
No
Not Sure/Maybe

a) medications

b) latex/rubber products

c) other (e.g. hay fever, seasonal/environmental, foods)

6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain. *

Yes
No
Not Sure/Maybe

Optional:

7. Do you have or have you ever had asthma? *

Yes
No
Not Sure/Maybe

8. Do you have or have you ever had any heart or blood pressure problems? *

Yes
No
Not Sure/Maybe

9. Do you have or have you ever had a replacement or repair of a hearth valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? *

Yes
No
Not Sure/Maybe

10. Do you have a prosthetic or artificial joint? *

Yes
No
Not Sure/Maybe

11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)? *

Yes
No
Not Sure/Maybe

12. Have you ever had hepatitis, jaundice or liver disease? *

Yes
No
Not Sure/Maybe

13. Do you have a bleeding problem or bleeding disorder? *

Yes
No
Not Sure/Maybe

14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain. *

Yes
No
Not Sure/Maybe

Optional:

15. Do you have or have you ever had any of the following? Please check *

chest pain, angina
heart attack
stroke, TIA
heart murmur
rheumatic fever
mitral valve prolapse
tuberculosis
cancer
pacemaker
lung disease
stomach ulcers
arthritis
steroid therapy
diabetes
thyroid disease
drug/alcohol/cannabis use or dependency
seizures (epilepsy)
kidney disease
shortness of breath
osteoporosis medications (e.g. Fosamax, Actonel)
none of the above

16. Are there any conditions or diseases not listed above that you have or have had? If yes, please explain. *

Yes
No
Not Sure/Maybe

Optional:

17. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)? *

Yes
No
Not Sure/Maybe

18. Do you smoke or chew tobacco products? *

Yes
No
Not Sure/Maybe

19. Are you nervous during dental treatment? *

Yes
No
Not Sure/Maybe

20. Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date? *

Yes
No
Not Sure/Maybe

21. Do you identify as a patient with a disability? If yes, please explain. *

Yes
No
Not Sure/Maybe

Optional:

To the best of my knowledge, the above information is correct:

Patient/Parent/Guardian Signature *

Date *

Dentist Signature

Date

Dentist Notes

Name

Convenient Scheduling

Monday 9:00am - 7:00pm
Tuesday 9:00am - 7:00pm
Wednesday 9:00am - 7:00pm
Thursday 9:00am - 7:00pm
Friday 9:00am - 7:00pm
Saturday By Appointment
Sunday Closed

Toronto Dental Office

56 Wellington St E, Toronto, ON M5E 1C7

info@dentistryonwellington.com

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Home
Meet Us
Guests
Services
Forms
- Covid-19 Wellness Screening Form
- Medical History Form
Blog
Contact Us
- Appointment Request
- Parking Options

Menu

Home
Meet Us
Guests
Services
Forms
- Covid-19 Wellness Screening Form
- Medical History Form
Blog
Contact Us
- Appointment Request
- Parking Options

Opening Hours

Monday 9:00am - 7:00pm
Tuesday 9:00am - 7:00pm
Wednesday 9:00am - 7:00pm
Thursday 9:00am - 5:00pm
Friday 9:00am - 4:00pm
Saturday TBD
Sunday Closed

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