Patient Information Form Step 1 of 4 25% Patient Name* First Last Nickname/Preferred Name: Date Of Birth:* Year Month Day Referred by: Primary Phone Number:*This is a:* Home Phone Cell Phone Please Note: Our office uses text message reminders that can only be sent to cell phones. If you do not use a cell phone, we can send reminders via email.Secondary Phone Number:This Is A: Home Phone Cell Phone Email Address:* Home Address / Mailing Address:* Street Address Address Line 2 City Province ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Name of Physician(s) and their Specialty: Doctor's Name Specialty Doctor's Name Specialty Doctor's Name Specialty What is your estimate of your general health?* Excellent Good Fair Poor Have you ever been hospitalized for an illness or injury?* Yes No If yes, reason for hospitalization, estimated date, and any complications experienced:Have you ever had an allergic or bad reaction to the following (please check):Aspirin Aspirin Type of reaction that occurred? Approximate date of reaction?NSAIDs (e.g. Ibuprofen, Naproxen) NSAIDs (e.g. Ibuprofen, Naproxen) Type of reaction that occurred? Approximate date of reaction?Acetaminophen (i.e. Tylenol) Acetaminophen (i.e. Tylenol) Type of reaction that occurred? Approximate date of reaction?Codeine Codeine Type of reaction that occurred? Approximate date of reaction?Penicillin Penicillin Type of reaction that occurred? Approximate date of reaction?Erythromycin Erythromycin Type of reaction that occurred? Approximate date of reaction?Clindamycin Clindamycin Type of reaction that occurred? Approximate date of reaction?Tetracycline Tetracycline Type of reaction that occurred? Approximate date of reaction?Sulfa Sulfa Type of reaction that occurred? Approximate date of reaction?Local anesthetic Local anesthetic Type of reaction that occurred? Approximate date of reaction?Fluoride Fluoride Type of reaction that occurred? Approximate date of reaction?Chlorhexidine Chlorhexidine Type of reaction that occurred? Approximate date of reaction?Metals (e.g. nickel) Metals (e.g. nickel) Type of reaction that occurred? Approximate date of reaction?Latex Latex Type of reaction that occurred? Approximate date of reaction?Nuts Nuts Type of reaction that occurred? Approximate date of reaction?Fruit Fruit Type of reaction that occurred? Approximate date of reaction?Other Other Type of reaction that occurred? Approximate date of reaction?I have not had allergic/bad reactions I have not had allergic/bad reactions DO YOU HAVE or HAVE YOU HAD (please check if applicable):Chest pain / angina Chest pain / angina Date diagnosed? How often do you experience chest pain / angina? Any precipitating factors? Duration of pain? What relieves the pain (ie nitroglycerin)? Any specialist treating this condition?High blood pressure High blood pressure Date diagnosed? Current treatment? Which doctor is treating this condition?Low blood pressure Low blood pressure Date diagnosed? Current treatment? Which doctor is treating this condition?High cholesterol High cholesterol Date diagnosed? Current treatment? Which doctor is treating this condition?History of infective endocarditis History of infective endocarditis Date diagnosed? Do you see a specialist and how often?Congenital heart defect (heart problem from birth) Congenital heart defect (heart problem from birth) Type and date diagnosed? Do you see a specialist and how often?Artificial heart valves or repair to valve Artificial heart valves or repair to valve Date of surgery? Do you see a specialist and how often?Heart attack / MI Heart attack / MI Date(s) diagnosed? Treatment (past or present)? Do you see a specialist and how often?Arrhythmia (e.g. irregular heart beat, atrial fibrillation) Arrhythmia (e.g. irregular heart beat, atrial fibrillation) Type and date diagnosed? Treatment (past or present)? Do you see a specialist and how often?Congestive heart failure Congestive heart failure Date diagnosed? Treatment (past or present)? Do you see a specialist and how often?Any heart conditions, heart surgery, or heart infections? Any heart conditions, heart surgery, or heart infections? What type of heart condition / infection do or did you have? Date diagnosed? What type of heart surgery did you have? Date of heart surgery and any complications experienced? Any specialist treating your condition(s)?Stroke (CVA) Stroke (CVA) Date(s) diagnosed? Any type of treatment (current or past)? Do you see a specialist and how often? Any residual effects?TIA (transient ischemic attack) TIA (transient ischemic attack) Date(s) diagnosed? Any type of treatment (current or past)? Do you see a specialist and how often? Any residual effects?Pacemaker Pacemaker Date inserted? Type of pacemaker? Do you see a specialist and how often?Implanted defibrillator (ICD) Implanted defibrillator (ICD) Date inserted? Do you see a specialist and how often?Epilepsy / seizures Epilepsy / seizures Type? Date diagnosed? Treating doctor or specialist? Triggers? Frequency? Date of last episode? Any treatment (past or present)? Any hospitalizations?Asthma Asthma Date diagnosed? Frequency of attacks? Severity of attacks (ie any hospitalizations)? Date of last attack? Triggers for the attacks (e.g. exercise, emotional upset, anxiety, stress)? Treatment (and how effective is the treatment)? Which doctor is treating this condition?Bronchitis Bronchitis Date(s) diagnosed? Treatment received? Which doctor is treating this condition?Any breathing problems (COPD, Emphysema, Shortness of breath) Any breathing problems (COPD, Emphysema, Shortness of breath) Type? Date diagnosed? Treatment received? Which doctor is treating this condition?Sleep Apnea Sleep Apnea Date diagnosed? Treatment received? Which doctor is treating this condition?Diabetes Diabetes Date diagnosed? Type of diabetes (1 vs 2)? Treatment (e.g. diet/ exercise, oral medications, and/or insulin)? Presence of complications (e.g. neuropathy, cardiac disease)? Which doctor is treating this condition? Most recent hemoglobin A1c level? Most recent blood glucose (blood sugar) level (fasting or non fasting)?Hypothyroidism Hypothyroidism Date of diagnosis? Current medication / any recent changes in dosage? Which doctor is treating this condition?Hyperthyroidism Hyperthyroidism Date of diagnosis? Treatment (past or present)? Note: if radiation treatment was it radioactive iodine or external beam radiation? Current medication / any recent changes in dosage? Which doctor is treating this condition?Hormone deficiency or imbalance Hormone deficiency or imbalance Type? Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Acid reflux / GERD Acid reflux / GERD Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Stomach ulcerations Stomach ulcerations Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Digestive disorder (e.g. Celiac disease) Digestive disorder (e.g. Celiac disease) Type? Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Liver problems (e.g. liver disease, cirrhosis, hepatitis) Liver problems (e.g. liver disease, cirrhosis, hepatitis) Type? Date diagnosed? Which doctor is treating this condition? Current status? Treatment (past or present)? Any known liver damage? Any known bleeding problems?Kidney disease Kidney disease Type? Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Sexually transmitted disease (e.g. HPV) Sexually transmitted disease (e.g. HPV) Type? Date diagnosed? Which doctor is treating this condition?HIV / AIDS HIV / AIDS Date diagnosed? Last CD4 count? Viral load if known? Treatment (past or present)? Which doctor is treating this condition?Prosthetic joint Prosthetic joint Which joint(s)? Month / year replaced? Any complications with the replacement (i.e. any infections)? Did the orthopedic surgeon recommend antibiotics before dental care?Arthritis (osteo or rheumatoid) Arthritis (osteo or rheumatoid) Type (osteoarthritis or rheumatoid)? Date diagnosed? Which joints affected? Treatment (past or present)? Which doctor is treating this condition?Osteopenia Osteopenia Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Osteoporosis or ever taken antiresorptive medications (i.e. bisphosphonates) Osteoporosis or ever taken antiresorptive medications (i.e. bisphosphonates) Date diagnosed? Name of medication? Medication taken orally or intravenously? Dosage / frequency of medication? Which doctor is treating this condition?Head or neck injuries Head or neck injuries Type of injury and approximate date(s)? Treatment (past or present)?Neurologic disorders (e.g. Alzheimer’s disease, dementia) Neurologic disorders (e.g. Alzheimer’s disease, dementia) Type? Date diagnosed? Which doctor is treating this condition?Concentration problems or ADD/ADHD Concentration problems or ADD/ADHD Date diagnosed? Which doctor is treating this condition?Major depression Major depression Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Anxiety disorders Anxiety disorders Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Bipolar disorder / schizophrenia / panic disorder / eating disorder Bipolar disorder / schizophrenia / panic disorder / eating disorder Diagnosis and date of diagnosis? Treatment (past or present)? Which doctor is treating this condition?Any bleeding problems Any bleeding problems Type of bleeding problem? Treatment (past or present)? Which doctor is treating this condition?Taking blood thinners Taking blood thinners Anemia Anemia Datę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Any problems with your immune system or take drugs that affect your immune system Any problems with your immune system or take drugs that affect your immune system Please provide more detail:Cancer Cancer Type of cancer? Date of diagnosis? Type / date of treatment, including when it finished? Follow up and future planned therapy? Current status of the disease? Which doctor is treating this disease?Chemotherapy Chemotherapy Radiation therapy Radiation therapy Taking steroids Taking steroids Reason for taking steroids?Tumour / abnormal growth Tumour / abnormal growth Diagnosis? Datę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Chronic ear infections Chronic ear infections Treatment (past or present)? Which doctor is treating this condition?Chronic sinus infections Chronic sinus infections Treatment (past or present)? Which doctor is treating this condition?Vertigo Vertigo Datę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Alcohol Use Disorder Alcohol Use Disorder Datę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Drug Addiction (Substance Use Disorder) Drug Addiction (Substance Use Disorder) Datę diagnosed? Treatment (past or present)? Which doctor is treating this condition?I confirm I have not had any of the conditions to my knowledge I confirm I have not had any of the above conditions to my knowledge ARE YOU:Presently being treated for any other illness or medical condition (not listed above)? Presently being treated for any other illness or medical condition (not listed above)? Please provide more detail:Often exhausted or fatigued Often exhausted or fatigued Experiencing frequent headaches or chronic pain Experiencing frequent headaches or chronic pain Please provide more detail:A smoker or vape user A smoker or vape user When did you start smoking / vaping? Approximately how often & how much do you smoke or vape?A previous smoker or vape user A previous smoker or vape user When did you start & stop smoking / vaping? Approximately how often & how much did you use to smoke or vape?Taking birth control Taking birth control Currently pregnant Currently pregnant What is your due date? Any complications experienced?Currently breastfeeding Currently breastfeeding I do not have any of the above conditions / they do not apply to me I do not have any of the above conditions / they do not apply to me Please list any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment:Are you presently taking any medications, supplements, vitamins, and/or probiotics?* Yes No List all medications, supplements, vitamins, and/or probiotics being taken (Include drug name, dosage, and purpose for taking it): Dental HistoryPrevious Dentist's Name: Doctor's Name Previous Dentist's Phone Number:How Long Were You A Patient? Do you have any specific dental concerns (please list):When Was Your Last Dental Appointment (Estimate If Necessary)? Year Month Day I routinely see my dentist every: 3 Months 4 Months 6 Months 12 Months Not routinely How would you rate the condition of your mouth?* Excellent Good Fair Poor On a scale of 1 to 10, how fearful of dental treatment are you, where 1 is not fearful and 10 is very fearful:12345678910Have you had an unfavourable dental experience? Yes No Have you ever had complications from past dental treatment? Yes No Have you ever had any trouble getting numb or had any reactions to local anesthesia? Yes No Did you ever have braces, orthodontic treatment or had your bite adjusted? Yes No Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma? Yes No Gum And BoneDo your gums bleed sometimes or are they ever painful when brushing or flossing? Yes No Have you ever been treated for gum disease or been told you have lost bone around your teeth? Yes No Have you ever noticed an unpleasant taste or odor in your mouth? Yes No Is there anyone with a history of periodontal disease in your family? Yes No Have you ever experienced gum recession, or can you see more of the roots of your teeth? Yes No Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? Yes No Have you ever experienced a burning or painful sensation in your mouth not related to your teeth? Yes No Tooth StructureHave you ever had any cavities within the last 3 years? Yes No Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? Yes No Do you feel or notice any holes (ie. craters) on the biting surface of your teeth? Yes No Are any teeth sensitive to hot, cold, biting, sweets or do you avoid brushing any part of your mouth? Yes No Do you have any grooves or notches on your teeth near the gum line? Yes No Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? Yes No Do you frequently get food trapped between any teeth? Yes No Bite And Jaw JointDo you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Yes No Do you clench or grind your teeth together in the daytime or make them sore? Yes No Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth? Yes No Do you wear or have you ever worn a bite appliance or night guard? Yes No In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed? Yes No Are your teeth becoming more crooked, crowded, or overlapped? Yes No Are your teeth developing spaces or becoming more loose? Yes No Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? Yes No Smile CharacteristicsIs there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, colour, size, display)? If so please explain:Have you ever whitened your teeth? Yes No Have you felt uncomfortable or self conscious about the appearance of your teeth? Yes No Have you been disappointed with the appearance of previous dental work? Yes No To Our Patients with InsuranceEach insurance benefit package varies considerably with regard to the different combinations of services included depending on the agreed benefits in place. The treatment options presented to you from our team are based upon our professional judgment and not based on your coverage by a dental benefit plan. As a courtesy to you, our staff may offer to process insurance claims on your behalf and submit a predetermination for any treatment you may require. We will help you in handling insurance queries, processing follow-ups or locating lost claims. No question is too small for you to ask, whether it is about your treatment, benefit plan, or statement. As a friendly reminder please note that your insurance policy is an agreement between you, your third-party health benefit provider(s) and/or the insurance company that provides your benefits. Not all services may be covered by your insurance plan. Any fees not covered by the benefit provider/ insurer are the patient's responsibility. We encourage you to fully understand your individual insurance plan. We cannot guarantee your individual coverage. It is your responsibility to update your information with us if there are any changes with your insurance plan. If you haven’t already provided our team with your insurance information, please send an email to [email protected] with your insurance card/ information, along with the policy holder’s date of birth. Optionally, please see our separate form titled “questions to ask your insurance provider” to obtain a breakdown of your plans coverage. Personal Information Patient ConsentAt Henley Dental, our entire team is committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. All of our privacy protocols comply with privacy legislation, standards of the Royal College of Dental Surgeons of Ontario, and the law. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted by law according to the provisions of the Regulated Health Professions Act. We collect information from our patients such as names, home addresses, telephone numbers, and e-mail addresses (collectively referred to us “Contact Information”). Contact information is collected and used for the following purposes: To open and update patient files To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts To process claims for payment or reimbursement from third-party health benefit providers and insurance companies To allow us to maintain communication and contact with you to discuss health care information and to book and confirm any appointments To send patients informational material about our dental practice All financial information is collected for payment processing purposes; it is not shared with third parties without your consent. We collect information from our patients about their mental and physical health, including family health history (Collectively referred to as “Medical Information”) to provide safe health care. Patient’s Medical Information is collected and used for the purpose of diagnosing dental conditions and advising you of treatment options. Patients’ Medical and Contact Information is disclosed: To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf. With the consent of the patient, to other dentists and dental specialists, or to other health care professionals. The storage, retention, and destruction of your personal information complies with existing legislation, and privacy protection protocols I consent to the collection, use and disclosure of my personal information as set out above;Date* Year Month Day Name First Last Signature*Cancellation and Payment PolicyPlease know that appointment times have been reserved especially for you, and any change in the schedule can affect many people. If for any reason you are unable to keep the reserved appointment time, we ask the courtesy of two business days notice to allow us to offer the time to another patient who may be waiting for an opening. Appointments canceled with less than two business days notice may be subject to a cancellation fee. Lastly, I understand that I am fully responsible for all amounts not covered by my third-party health benefit provider(s) and/or insurance company, and are due at the end of my appointment, when services are rendered. For your convenience, Henley Dental accepts the following forms of payments: Cash, Debit, all major Credit Cards (Visa, Mastercard, American Express), and personal cheques. I consent to the above Cancellation and Payment Policy as set out by Henley Dental.Signature*CommentsThis field is for validation purposes and should be left unchanged.