5 Year Medical History Update - Kitchener Dentist

5-Year Medical Update Form

Lancaster Dental

493 Lancaster Street West, Suite #206
Kitchener, ON N2K 1L8
Phone: 519-578-9670
Today's Date*
DD slash MM slash YYYY
Patient Name*
First Middle Last
Date of Birth*

Day
Month
Year
Age*
Family Status*
Gender
What sex were you assigned at birth?
What is your current gender identity?
Specify Current Gender
Preferred Gender Pronoun
A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!
What pronouns do you prefer that we use when referring to you? (check all that apply)
- She/her/hers
- He/him/his
- They/them/theirs
- Other
Specify pronoun
Contact Information
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Email*
Work Phone
Extension Number
Health Card Number
Family Physician*
First Last
Physician's Phone*
In Case of Emergency, We should notify:*
First Last
Relationship*
Phone*
Employer Name
Occupation
Medical & Dental Information
Do you or have you ever had an adverse reaction or allergy to:
Antibiotic
- Yes
- No
Which Antibiotic
Aspirin/Advil
- Yes
- No
Codeine
- Yes
- No
Latex
- Yes
- No
Local Anesthetics/Novocain
- Yes
- No
Other
- Yes
- No
Please Specify
Do you take blood thinners (e.g Coumadin, Plavix, etc.)*
Specify the date and score of most recent INR
Do you take any other medications, vitamins or supplements*
List any medications and dosage (including Herbal)*
Have you ever had any of the following? Please check those that apply:
Neural
- Seizures/Epilepsy
- Seizures/Epilepsy
- Dizziness
- Nervous/Mental Disorders
- Stroke
- Depression
Cardiovascular
- Angina
- Heart Attack
- Bleeding Disorder
- High/low Blood Pressure
- Heart Disease
- Pacemaker
- Rheumatic fever
- Heart Murmur
Pulmonary
- Asthma / COPD
- Difficulty breathing
- Respiratory problems
- Tuberculosis
Infectious
- AIDS/ HIV
- Hepatitis A B C
- Venereal Disease
Immune
- Hay fever
- Allergy
Neoplastic
- Cancer
- Growths/Tumors
- Radiation/Chemo
Digestive
- Acid reflux Disease
- Stomach Problems
- Ulcers
Inflammatory
- Arthritis
- Rheumatism
- Osteoporosis
Other
- Diabetes
- Artificial Joints
- Glaucoma
- Sinus Problems
- Liver Disease
- Kidney Disease
- Sleep Apnea
- Organ Transplant
- Thyroid problems
Where do you keep your inhaler?
Specify any of the above conditions
Surgery Details
If you had any surgeries please specify the surgery date and information.
Are there any conditions or diseases not listed above that you have or have had?*
What are they?
Have you ever had any complications following dental treatment?*
Please explain
Have you or anyone related to you ever had problems with local anesthetic?*
Please explain
Are you pregnant or is it possible you are pregnant?*
Due Date

Day
Month
Year
Are you now under the care of a physician, regarding an ongoing medical issue?*
Please explain
Do you have any health problems that need further clarification?*
Please explain
Do you smoke?*
How many cigarettes a day?
When did you quit?

Day
Month
Year
Do you use any recreational drugs?*
Please list which kind:
Do you have a prosthetic or artificial joint ?*
Where ?
Do you have or have you ever had replacement or repair of a heart valve, infection of the heart(i.e. infection endocarditis), a heart condition from birth (i.e. congenital heart disease) or heart transplant?*
When was your last dental visit ?*
When did you last have dental x-rays ?*
How often do you floss your teeth ?*
How often do you brush your teeth ?*
Have you been seeing a dentist regularly ?*
Do any of your teeth ache ?*
Do your gums bleed when you brush ?*
Do you have pain when you chew ?*
Do you feel you have bad breath ?*
Please list anything else not mentioned above regarding your past dental history.
Consent for Services & Office Agreement
* I understand that my family’s appointments are valuable, and that 2 Business days must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.

*I will be required to pay for my family treatment at each visit. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (this is separate from Dental office fees).

*I understand that outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.

*I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.

*My dental insurance plan is a contract between myself and the organization providing me with the coverage. It is my responsibility to ensure that the treatment I request is covered. However, Lancaster Dental will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Lancaster Dental has NO knowledge of what is covered by my insurance plan. If I have a booklet, Lancaster Dental will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. Lancaster Dental will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.

* Lancaster Dental also understands that your time is valuable so we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible) we will not double book appointments.

* Lancaster Dental will always make every attempt to see emergency cases promptly.

* Lancaster Dental will accept Visa, MasterCard, debit, cash or cheque.

* Lancaster Dental will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

Consent for Collection, Use and Disclosure of Personal Information

* I agree that Lancaster Dental has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.
Consent*
I have read the above conditions of treatment and payment and agree to their content. I confirm that best to my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Signature of patient, parent or guardian (Type in Your Name)
Date*
DD slash MM slash YYYY

5-Year Medical Update Form

Lancaster Dental

Gender

Preferred Gender Pronoun

Contact Information

Medical & Dental Information

Do you or have you ever had an adverse reaction or allergy to:

Have you ever had any of the following? Please check those that apply:

Consent for Services & Office Agreement