Patient Information Form Patient Name* First Last Nickname/Preferred Name:Date Of Birth:* YYYY MM DD Primary Phone Number:*This is a:*Home PhoneCell PhonePlease 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 PhoneCell PhoneEmail 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?*ExcellentGoodFairPoorHave you ever been hospitalized for an illness or injury?*YesNoIf yes, reason for hospitalization and estimated date:Have you ever had an allergic or bad reaction to the following (please check):* Aspirin, Ibuprofen, acetaminophen, codeine penicillin eythromycin textracycline sulfa local anesthetic flouride chlorhexidine Chlorhexidine Metals (nickle, gold, silver ect) Latex Nuts Fruit other I have not had allergic/bad reactionsDO YOU HAVE or HAVE YOU HAD (please check if applicable):* Heart problems or cardiac problems History of endocarditis; chest pain / angina Artificial heart valve or a repaired heart defect Pacemaker or Implantable defibrillator Orthopedic or soft tissue implant (e.g. joint replacement, breast implant) Heart murmur, rheumatic or scarlet fever High or low blood pressure A stroke (taking blood thinners) Anemia or other blood disorder Prolonged bleeding due to a slight cut Pneumonia, emphysema, shortness of breath, sarcoidosis Chronic ear infections Breathing problems (e.g. asthema, chronic bronchitis) Sleep problems (eg. sleep apnea, bedwetting) Kidney disease Liver disease or jaundice Vertigo Thyroid, parathyroid or calcium deficiency Hormone imbalance High cholesterol or taking statin drugs Diabetes Stomach Ulcer Digestive or eating disorder (ex. Celiac disease, gastric reflux, bulimia, anorexia) Osteoporosis / Osteopenia or ever taken anti-resorptive medications Arthiritis or gout Autoimmune disease Glaucoma Head or neck injury Epilepsy or seizures Neurological disorders (ADD / ADHD, prion disease) Viral infections and cold sores Hives, skin rash, hay fever STI / STD / HPV Hepatitis. If so please note which type: HIV / AIDS Cancer Radiation therapy Chemotherapy or immunosuppressive medication, steroid therapy Psychiatric treatment or antidepressant medication Had botox or collagen injections Alcohol / recreational drug use I confirm I have not have any of the conditions to my knowledgePlease provide more details:ARE YOU:* Presently being treated for any other illness? Taking dietary supplements? Often exhausted or fatigued Experiencing frequent headaches A smoker, smoked previously or use vapes Taking birth control Currently pregnant Currently breast feeding I do not have any of the above conditions / they do not apply to mePlease provide more information: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, or vitamins?*YesNoList all medications, supplements or vitamins 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)? YYYY MM DD I routinely see my dentist every:3 Months4 Months6 Months12 MonthsNot routinelyOn 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?YesNoHave you ever had complications from past dental treatment?YesNoHave you ever had any trouble getting numb or had any reactions to local anesthesia?YesNoDid you ever have braces, orthodontic treatment or had your bite adjusted?YesNoHave you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma? Yes NoGum And BoneDo your gums bleed sometimes or are they ever painful when brushing or flossing?YesNoHave you ever been treated for gum disease or been told you have lost bone around your teeth?YesNoHave you ever noticed an unpleasant taste or odor in your mouth?YesNoIs there anyone with a history of periodontal disease in your family?YesNoHave you ever experienced gum recession, or can you see more of the roots of your teeth?YesNoHave you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?YesNoHave you ever experienced a burning or painful sensation in your mouth not related to your teeth?YesNoTooth StructureHave you ever had any cavities within the last 3 years?YesNoDoes the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?YesNoDo you feel or notice any holes (ie. craters) on the biting surface of your teeth?YesNoAre any teeth sensitive to hot, cold, biting, sweets or do you avoid brushing any part of your mouth?YesNoDo you have any grooves or notches on your teeth near the gum line?YesNoHave you ever chipped teeth, broken teeth or had a cracked filling?YesNoDo you frequently get food trapped between any teeth?YesNoBite And Jaw JointDo you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)YesNoDo you clench or grind your teeth during the day?YesNoDo you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?YesNoDo you wear or have you ever worn a bite appliance or night guard?YesNoSmile CharacteristicsIs there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)? If so please explain:Have you ever whitened your teeth?YesNoHave you felt uncomfortable or self conscious about the appearance of your teeth?YesNoHave you been disappointed with the appearance of previous dental work?YesNoPersonal 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 filesTo invoice patients for dental services, to process credit card payments, or to collect unpaid accountsTo process claims for payment or reimbursement from third-party health benefit providers and insurance companiesTo allow us to maintain communication and contact with you to discuss health care information and to book and confirm any appointmentsTo 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* YYYY MM DD Name First Last Signature*