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- Medical History
Before & After
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Contact Us

Home
Our Team
New Patients
Dental Services
Promotions
- Medical History
Before & After
Oral Tips
Contact Us

Free Phone Consultation

Home
Our Team
New Patients
Dental Services
Promotions
- Medical History
Before & After
Oral Tips
Contact Us

Home
Our Team
New Patients
Dental Services
Promotions
- Medical History
Before & After
Oral Tips
Contact Us

Free Phone Consultation

Medical & Dental History Form

Section A - Medical History

Patient Name:

Email:

Please take a moment to let us know about your medical and dental history so we may serve you more effectively and in a way that watches out for your overall health and well-being.
Would you consider yourself to be in fairly good health?

Yes No

Within the past year, has anything changed in your general health?

Yes No

What is the date (or approximate date) of your last medical exam?

Your Primary Care Physician's name, address, & phone number:

List all medications you take (prescripton, herbal and over the counter)

Please mark any of the following to indicate Yes in response to the question:

Have you ever had complications following dental treatment? complications following dental treatment? Are you currently under the care of a physician due to a specific condition? Have you been hospitalized within the last 5 years due to a surgery or illness? Do you use tobacco (smoking or chewing or other)?

If any of the previous questions are marked, please explain:

Gender

Male Female Prefer not to answer

WOMEN ONLY: Are you pregnant?

Yes No

Are you nursing?

Yes No

Please indicate if you have experienced any of the following:

*Pre-Medication *See Patient Notes *Allergy - See Notes Allergy - Aspirin Allergy - Codeine Allergy - lodine Allergy - Latex Allergy - Penicillin Allergy - Sulfa Allergy-Erythromicin Allergy-Local Anesth Anemia Arthritis Artificial Joints Asthma Autism Avalox Bleeding Disorden Blood Clots Blood Disease Cancer Celiac Disease Clindamycin Contraceptive Use Demerol Diabetes Dizziness/Fainting Emphysema Endometrosis Epilepsy Excessive Bleeding Excessive Bruising Gastro-Intestinall Glaucoma HBP HIV+ (AIDS) Hard To Freeze Hay Fever Head Injury Hearing Disabled Heart Disease Heart Murmur Hepatitis A Hepatitis B Hepatitis C Hives Jaundice Kidney Disease LBP Liver Disease Mental Disorders Multiple Sclerosis Nervous Disorders Pacemaker Penicilin Pregnancy Pulmonary Embolism Radiation Treatment Raynaud's Disease Respiratory Problems Rheumatic Fever Rheumatism Rheumatoid Arthritis SID Sinus Problems Skin Rash Stomach Problems Stroke Sulfa IMJ Thyroid Disease Tuberculosis Tumors Ulcers Weelchair acid reflux advil ampicillin anticoagulant blood pressure cannot take nsaids cholestrol cortisone kidney transplant labatole meniscus nickel parkinson post coricsion syndro preeclampsia reduce colestorol reduce heart attack stomach ulcer tetracycline vitiligo

Do you have any other conditions, discases, otc., not listed that we should be aware of? (if yes, please explain)

Yes No

Section B - Dental History

What is the reason for your dental visit today?

What was done on your last dental visit (if to a different office)?

Prior Dentist's name, address, & phone number:

Are you tense during dental visits?

Yes No

i consider clental care as:

I have alvays done what was recommended to me I put dental care high on my priority list for myself I put dental care low on my list I have never considered my dental care

How important my teeth are:

Very important Only within a certain budget Indifferent

How do you evaluate your current dental health

Excellent Good Poor

I consider my mouth as:

Very comfortable Moderately comfortable Uncomfortable

I consider the appearance of my smile as:

Excellent Satisfied Change

If you could change anything about your mouth, teeth, or smile, what would it be?

How frequently do you brush your teeth?

3 (+) a day Twice a day Once a day Weekly Seldom

How frequently do you floss your teeth?

1 (+) a day 2 - 6 weekly 1 - 6 monthly Seldom Never

Do your gums bleed when you brush or floss?

Yes No

Would you like to have whiter teeth?

Yes No

Do your teeth experience sensitivity to cold or hot temperatures?

Yes No

Are any of your teeth currently causing you pain?

Yes No

Do you grind your teeth (either consciously or during sleep)?

Yes No

Are any of your teeth loose, or are you concerned about any teeth loosening?

Yes No

Do you currently have any dental implants, dentures, or partials?

Yes No

Are your teeth straight?

Yes No

Section C - TMJ Health Questionaire

Please, list any symtoms that you want to bring to my attention

Please, indicate your current degree of pain level by selecting the corresponding number, using the scale 0-10 for self-assessment.

No pain Mild Moderate Severe Worse pain possible

TMJ clicking/grating

0 1-2 3-4 5 6-7 8-9 10

TMJ locking/ stiffness

0 1-2 3-4 5 6-7 8-9 10

Inability to open mouth

0 1-2 3-4 5 6-7 8-9 10

Mouth doesn't open straight

0 1-2 3-4 5 6-7 8-9 10

Pain when eating/chewing

0 1-2 3-4 5 6-7 8-9 10

Pain in jaw or jaw joint

0 1-2 3-4 5 6-7 8-9 10

Unstable bite

0 1-2 3-4 5 6-7 8-9 10

No pain Mild Moderate Severe Worse pain possible

Headache

0 1-2 3-4 5 6-7 8-9 10

Face pain

0 1-2 3-4 5 6-7 8-9 10

Ear pain/Stiffiness

0 1-2 3-4 5 6-7 8-9 10

Ringing in ears

0 1-2 3-4 5 6-7 8-9 10

Difficulty swallowing

0 1-2 3-4 5 6-7 8-9 10

Neck Pain

0 1-2 3-4 5 6-7 8-9 10

Muscle fatigue

0 1-2 3-4 5 6-7 8-9 10

Do you get migraine headaches?

Yes No

Do you have trouble sleeping soundly?

Yes No

Are your teeth sore when you awaken?

Yes No

Do you clench your teeth during the day/night?

Yes No

Do you grind your teeth when your asleep?

Yes No

Contact info

Address

1104 Klondike Rd, Kanata, ON K2K 0G1, Canada

Business Phones:

Email Us: smile@anatadental.com

OPENING HOURS

Monday – Thursday – 8:00 am to 4:00 pm

Friday – 8:00 am to 3:00 pm

Saturday – 9:00 am to 4:00 pm

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