New Patient Intake form

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New Patient Intake form

Step 1 of 2

WELCOME TO MANOTICK MAIN DENTAL
- Adult
- Child
Name
First Middle Last
Prefers to be called
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Date of Birth
MM slash DD slash YYYY
- Male
- Female
Employer
Phone
Occupation
School
Grade
Would you be available on short notice for future appointments or appointment changes?
May we call you at work?
Email
Whom may we thank for referring you to our office?
Family Physician:
Phone
In case of emergency
Relation
Phone
Person responsible for this account:
- Self
- Spouse
- Parent
- Legal Guardian
- Other
Person responsible for this account Other Option Selected
Name
First Middle Last
Prefers to be called
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Payment by
- Cash
- Cheque
- Credit Card
Credit Card Number
Credit Card Expiry Date
Primary Insurance
Subscriber
Relation (Primary)
- Self
- Spouse
- Other
Primary Insurance Relation Other
Insurance Co
Policy / Plan
Division/Sect
Subscriber ID or S.I.N. #
Are you familiar with your plan details?
- Yes
- No
Coverage
- A
- B
- C
- D
SecondaryInsurance
Subscriber
Relation (Secondary)
- Self
- Spouse
- Other
Secondary Insurance Relation Other
Insurance Co
Policy / Plan
Division/Sect
Subscriber ID or S.I.N. #
Are you familiar with your plan details?
- Yes
- No
Coverage
- A
- B
- C
- D
MEDICAL HISTORY
All information is confidential
Y =Yes ? =Don’t know/Maybe N = No
The following information is required by the dentist to assist in proper diagnosis and treatment
1. Have you ever had a serious illness requiring hospitalization or extensive medical care?
- Y
- N
- ?
Please specify:
2. Have you been hospitalized in the last 5 years?
- Y
- N
- ?
3. Are you presently under the care of a physician?
- Y
- N
- ?
If yes, why?
4. Have you had medical examination in the last year?
- Y
- N
- ?
5. Do you use any prescription or non-prescription drugs regularly?
- Y
- N
- ?
Please specify:
6. Do you have any allergic conditions: i.e. Hay fever, skin rash, food allergies, metal, latex?
- Y
- N
- ?
Please specify:
7. Do any allergic reactions result in headaches, shortness of breath, chest constriction, nausea?
- Y
- N
- ?
Please specify:
8. Have you ever experienced any unusual reaction to any of the following (please circle) Local anesthesia (freezing), aspirin, penicillin, codeine, sulpha drugs, barbiturates (sleeping pills), or any other medicine?
- Y
- N
- ?
If so, please explain
9. Have you been warned against taking any drug or medication?
- Y
- N
- ?
10. Do you bruise easily or bleed abnormally?
- Y
- N
- ?
11. Have you ever had an organ transplant or medical implants?
- Y
- N
- ?
12. Have you ever fainted?
- Y
- N
- ?
13. Do your ankles swell during the day?
- Y
- N
- ?
14. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?
- Y
- N
- ?
15. Do you have frequent headaches / earaches / ear or throat infections or hearing difficulty?
- Y
- N
- ?
16. Do you have AIDS or had contact with the AIDS virus or have you ever tested positive for HIV?
- Y
- N
- ?
17. Do you have or have you ever had any of the following? (please tick)
- Y
- N
- ?
- Heart murmur or Mitral valve prolapse
- Stomach / Intestinal problems / Ulcers
- Joint replacement (hip, knee, etc)
- Mental or nervous disorder
- High / Low blood pressure
- Hyper / Hypo glycemia
- Epilepsy or seizures
- Cortisone / Steroid therapy
- Malignant hyperthermia
- Drug / Alcohol dependency
- Venereal disease
- Lung disease (i.e. asthma)
- Thyroid disease
- Arthritis or Rheumatism
- Scarlet or Rheumatic fever
- Cancer / Chemotherapy
- Liver disease
- Heart attack
- Cold sores
- Jaundice
- Diabetes
- Tuberculosis
- Hepatitis A / B / C
- Herpes
- Sinus trouble Stroke
- Kidney problems
- Emphysema
- Glaucoma
- Other
17. Do you have or have you ever had any of the following? Other Response
18. Have you had any injury, surgery or x-ray therapy to your face or jaws?
- Y
- N
- ?
19. Do you have any other disease, condition, or problem that you think the doctor should know about?
- Y
- N
- ?
Details
20. Women Only
Are you pregnant or suspect you might be? If so, what month are you in?
- Y
- N
- ?
Details
Are you taking birth control pills?
- Y
- N
- ?
Are you pregnant or suspect you might be? If so, what month are you in?
- Y
- N
- ?

New Patient Intake form

Get in touch

New Patient Intake form

Step 1 of 2

WELCOME TO MANOTICK MAIN DENTAL

Primary Insurance

SecondaryInsurance

MEDICAL HISTORY

20. Women Only

DENTAL HISTORY

See What Our Manotick Dentist Can Do For You