dental clinic Floss in Hawkesbury

First visit form

When you come in for your first appointment, you will have to fill out a form giving us all the relevant information on your health. To speed things up, please fill out the form ahead of time and send it to us on line or print it and bring it with you. Rest assured that all information will remain confidential.

Appointment cancellations must be made by telephone or e-mail at least 48 hours in advance or a service charge will apply.

Personal Information (fields marked with an asterisk are mandatory)

Last name:*
First name:*
Gender: M   Age :
Address:*
City:*
Postal code:
Home telephone:*
Work telephone: Extention: 
E-mail:*
Weight:
Height:
Birth date: Year: 
Medicare Card No:
Expiry: Year: 
If child, parent's name:
In case of emergency call:
Reason for visiting us:

Medical History

Are you currently under the care of a physician?
If yes, provide his/her name
Physician's Tel:
Are you currently taking or have you taken any medication in the last six months?
If yes, please descrive them below:
Avez-vous eu une perte ou un gain de poids marqué dernièrement?
Are you pregnant? Are you taking a hormonal contraceptive?
Do you or have you ever had any of the following:
Heart disease (infarction, angina, valve problems, shortness of breath)?
Rheumatic fever? Prolonged bleeding? Anemia ?
Blood pressure? Frequent colds or sinusitis ?
Tuberculosis or lung problems? Digestive problems ?
Stomach ulcers?
Liver problems (hepatitis A, B, C or cirrhosis) Kidney problems?
Sexually transmitted infections (STIs)? Diabetes?
Thyroid problems? Skin disease?
Vision problems? Arthritis? Epilepsy?
Nerve problems? Frequent headaches?
Étourdissements, évanouissements? Earaches ?
Hay fever? Asthma ? Do you smoke ?
Have you ever had radiation treatments or chemotherapy?
Do you have acquired immunodeficiency syndrome (AIDS)?
Have you tested positive for AIDS?
Do you have any joint prostheses?
Have you ever had an allergic reaction to any of the following:
Foods Penicillin Aspirin Iodine
Sulpha drugs Codeine Local anesthetic
Others:
Explain:
Have you ever been hospitalized or undergone surgery, other than dental surgery?
If yes, specify the type of surgery and when:
Do you wish to discuss your health with the dentist?
Comments

Dental History

Date of last dental visit: 0-6 months  6-12 months  +than 12 months
Treatment received
Have you had any of the following dental treatments or services?
Oral hygiene demonstration? Gum treatment?
Orthodontic treatment (braces)? Root canal treatment?
Fillings? Crown(s) or bridge(s)?
Full or partial prostheses?
Dental surgery or extraction?
Dental implants? Dental x-rays? Others ?



Thank you for taking the time filling in this form. We are looking forward meeting you on your next meeting.
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   Plaza Hawkesbury, 460 County Road 17, Hawkesbury