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About Us
Dental Services
Cosmetic Dentistry
Dental Crowns & Bridges
Dental Cleaning / Hygiene
Dental Implants
Laser Dentistry
Invisalign
Restorative Dentistry
Pediatric & Kids Dentistry
Veneers
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Braces
Emergency Dental
Reviews
Financing and Insurance
Locations
J Dental – Lakeshore
Sahar Dentistry – Etobicoke
Sahar Dentistry – Erin Mills
BOOK AN APPOINTMENT
Medical Alert
Name
First
Last
Email
Phone
Date of Birth
MM slash DD slash YYYY
Occupation
Address
Street Address
City
Province
Postal Code
Who referred you to our office?
Emergency Contact Details
Name
Relationship
Day Time Phone
Name of Family Doctor
Phone or Address
1) Name of Medical Specialist
Area of Speciality
Phone or Address
2) Name of Medical Specialist
Area of Speciality
Phone or Address
Insurance Carrier Detail
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Dental History
What is the reason for your visit today? Are you currently experiencing any dental problems?
Have you been seeing a dentist regularly? if not, why not?
Are you nervous during dental treatment?
Yes
No
Not Sure/Maybe
Have you had a bad experience or complications during dental treatment?
Yes
No
Not Sure/Maybe
Have you ever seen a dental specialist?
Yes
No
Not Sure/Maybe
Last dental visit? What was done during the appointment (months/years ago)
How often do you brush your teeth? Do your gum bleed when you brush or floss?
Have you been advised to take antibiotics before dental appointment?
Yes
No
Not Sure/Maybe
Do you feel that you have bad breath?
Yes
No
Not Sure/Maybe
Are you happy with the appearance of your teeth?
Yes
No
Not Sure/Maybe
Are you happy with the appearance of your teeth?
Yes
No
Not Sure/Maybe
Do you have any problems with your jaw ( clicking, limited movement, pain)?
Yes
No
Not Sure/Maybe
Have you ever had an injury to the teeth or jaws or been involved in a moter vehicle accident?
Yes
No
Not Sure/Maybe
Have you had a complete exam of own full X-rays series within the last 3 years?
Yes
No
Any habits
Clenching
Mouth Breathing
Cheek Biting
Others
Are you concerned about the following dental problems
Teeth Sensitivity
Bad Breath
Bleeding Gums
Loose / Shifted Teeth
Food Catching in between teeth
Frequent blisters on lips or mouth
Medical History
Are you being treated for any medical condition at the present or have you been treated within the past year
Yes
No
Not Sure
If yes ,please explain?
When was your last medical checkup ?
Has there been any change in your general health in the past year? If yes, please explain
Have you ever had a major illness / surgery?
Yes
No
Not Sure
Are you taking medications, non-prescription drugs or herbal supplements of any kind? If yes, please list with dosages
Do you have allergies? If yes please list them using categories below
Yes
No
Not Sure/ Maybe
a) Medications
b) Latex/ Rubber products
c) Other (hay fever, seasonal/environmental, food etc.)
Have you ever had an unusual or adverse reaction to any medicines or injections?
Yes
No
Not Sure
If yes ,Why?
Do you have or have you ever had asthma? Bronchitis? Pneumonia? (If yes, please indicate)
How often do asthmatic attacks occur?
What triggers these attack?
When did the last attack occur?
Do you have a prosthetic or artificial joint?
Yes
No
Not Sure / Maybe
Do you have any conditions or therapies that could affect your immune system? (e.g. Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy))
Yes
No
Not Sure / Maybe
Have you ever had hepatitis, jaundice or liver disease?
Yes
No
Not Sure / Maybe
Do you have a bleeding problem or bleeding disorder?
Yes
No
Not Sure / Maybe
Have you ever been hospitalized for any illnesses or operations?
Yes
No
Not Sure / Maybe
Do you have or have ever had any heart infection (infective endocarditic) heart valve repair or replacement congenital heart disease (from birth?)
Yes
No
Are there any conditions that run in your family?
Do you smoke or chew tobacco products?
Yes
No
For women only: Are you breast feeding or pregnant?
Yes
No
Do you Identify as a patient with disablity?
Yes
No
Not Sure/Maybe
If Yes, please explain
Please elect any condition that you have now or had in the past
Asthma
Artificial pin /plate
Alcohol use
Addiction
Arthritis
Anemia
Bleeding Disorders
Blood Transfusions
Cholesterol
Congenital Heart Defect
Cortisone treatment
Cardiac pacemaker
HIV / AIDS
Heart trouble / Angina
High Blood pressure
Hemophillia
Herpes
Hepatitis A , B or C
Fainting Spells
Malignant Hyperthermia
Heart Murmur
Immune Therapy / Disease
Inflammatory Bowel Disease
Stroke
Sickle cell disease
Sinus Trouble
Stomach Ulcer
Tuberculosis
Cancer
Diabetes
Epilepsy
Kidney Disease
Lupus
Liver Disease
Low Blood Pressure
Thyroid Disease
TMJ Problems
Sexually transmitted
Diseases Chemotherapy
Are there any conditions or diseases you have that have not been listed?
Yes
No
Are there any conditions or diseases you have that have not been listed?
Consent
I agree and Consent to the following.
I, the undersigned, certify that I have provided an accurate and complete personal and medical- dental history and have not knowingly omitted the information. I have had the opportunity to ask questions and receive answers to my questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand the consultation with my medical doctor may be required, and I consent to my physician being contacted if necessary
Consent
I agree to the privacy policy.
Signature
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About Us
Dental Services
Cosmetic Dentistry
Dental Crowns & Bridges
Dental Cleaning / Hygiene
Dental Implants
Laser Dentistry
Invisalign
Restorative Dentistry
Pediatric & Kids Dentistry
Veneers
Dentures
Braces
Emergency Dental
Reviews
Financing and Insurance
Locations
J Dental – Lakeshore
Sahar Dentistry – Etobicoke
Sahar Dentistry – Erin Mills
BOOK AN APPOINTMENT
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