5 Year Medical Update Form

Highland Kitchener Dentist

140 Highland Rd. West,
Kitchener, ON N2M 3B8
Phone: (519) 885-1598

Today's Date*

Patient Name*

First Middle Last

Date of Birth*

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

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?

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, Highland Kitchener Dentist will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Highland Kitchener Dentist has NO knowledge of what is covered by my insurance plan. If I have a booklet, Highland Kitchener Dentist will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. Highland Kitchener Dentist 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.

* Highland Kitchener Dentist 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.

* Highland Kitchener Dentist will always make every attempt to see emergency cases promptly.

* Highland Kitchener Dentist will accept Visa, MasterCard, debit, cash or cheque.

* Highland Kitchener Dentist 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 Highland Kitchener Dentist 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*

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