Adult Medical Health Questionnaire

This form will take several minutes and your progress can't reliably be saved for later if it's left unfinished. Before starting, please ensure you can complete it in one attempt. Your completed questionnaire will only be sent to us when you press the final Submit button.

We take security & privacy seriously. When you fill out this form online, your details will be stored in our secure database and will not be sent anywhere by email.

If you have any questions, please phone our office during regular business hours (found on this page).

- Step 1 of 4

Patient Information

Patient's legal first name *

Legal last name *

Alternate / preferred first name

Optional - only if different than above

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioQuebecPrince Edward IslandSaskatchewanYukonProvince

Postal Code

Mobile phone *

Home phone

Business phone

Email *

Occupation

Age *

Birthdate (DD/MM/YYYY) *

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Gender *

• Female
• Male
• Other

Note: Our medical software is limited to the options of Male and Female, and choosing one of those 2 options is a requirement. If you identify otherwise, we sincerely apologize that we aren’t able to record this accurately. Please choose which gender we should put on your file, and you can also specify your pronouns, below.

Gender (for patient file) *

• Female
• Male

Pronouns *

• She / her
• He / him
• They / them
• Let me type...

This helps us understand the best way to address you.

How shall we address you? *

Do you currently have a dentist? *

• Yes
• No

Dentist's name *

Dentist's office phone number *

This ensures we find the correct dentist with the provided name.

Who may we thank for referring you to our office? *

• Dentist
• Patient
• Other

Patient's name *

Please specify (other) *

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Medical History

General health: *

• Excellent
• Good
• Fair
• Poor

Details of your general health: *

Are you currently taking any prescription or non-prescription drugs? *

• Yes
• No

Medication details: *

Is there any history of allergies? (i.e. metals, environmental, medications) *

• Yes
• No

Allergy details: *

Is there a history of a heart murmur or mitral valve prolapse? *

• Yes
• No

Heart condition details: *

Do you require antibiotics prior to dental appointments? *

• Yes
• No

Is there a history of conditions that could affect the immune system? (i.e. leukemia, autoimmune diseases, HIV) *

• Yes
• No

Immune system details: *

Is there a tendency to bruise easily or bleed for a prolonged period of time after being cut? *

• Yes
• No

Bruising / bleeding details: *

Do you currently smoke, vape or use tobacco products? *

• Yes
• No

Type of product and frequency of use *

Is there a history of emotional disorders or mental health? *

• Yes
• No

Mental health details: *

Is there a history of eating disorders? *

• Yes
• No

Eating disorder details: *

(If applicable) Are you pregnant or is there a possibility that you may be? *

• Yes
• No

Pregnancy details: *

**Important** Are there any privacy concerns regarding the knowledge of your pregnancy, such as with anyone who may accompany you to your appointment(s)? You may also specify how many weeks/months pregnant, or your due date.

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Dental History

Why are you seeking an orthodontic evaluation? *

Has any other family member had orthodontic treatment? *

When was the most recent dental visit? *

When were the last dental x-rays taken? *

Thumb / finger sucking habit? *

• Yes, in the past
• Yes, presently
• No

Finger sucking details: *

e.g. which fingers, and until what age

Finger sucking details: *

e.g. which fingers, type of habit

Accidents/trauma involving the teeth/jaws/nose? *

• Yes
• No

Nature of injury (incl. which teeth, if applicable), when it happened, and the healing outcome. *

Tooth extractions? *

• Yes
• No

(e.g. wisdom teeth, or otherwise)

Which teeth? When? *

Are you being monitored by a dental specialist? (e.g. gum specialist) *

• Yes
• No

Doctor's name *

Previous orthodontic consultations? *

• Yes
• No

Doctor's name *

Previous orthodontic treatment? *

• Yes
• No

Previous orthodontic treatment details: *

Please list anything else not mentioned above regarding the past dental history

Please list any sports, musical instruments or hobbies

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Note: As part of the Regulated Health Professions Act (PIPEDA), we are required to ask for permission to be able to correspond with other associated healthcare personnel (i.e. family dentist, physician)

Do you authorize permission, as per the statement above? *

• Yes
• No

Please provide details as to why not *

Signature *

Clear Signature

Additional comments (optional)

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