Medical Information Record - Adult

You may complete the Patient History form below and submit the data online. You can also download and print the following 2 PDF files and bring the completed forms to your first visit. The forms are compliant with Personal Information Protection and Electronic Documents Act (PIPEDA). Please fill out all items to your best knowledge. Fields marked with an asterisk(*) are required.

    PATIENT INFORMATION

  • MaleFemale
  • How did you become acquainted with our office?
  • Please describe the reason(s) for seeking orthodontic treatment.
  • In case of Emergency, we should contact

    MEDICAL/DENTAL INSURANCE

MEDICAL HISTORY

The following information is required to enable us to provide you with the best possible care. All information is strictly private and is protected by doctor-patient confidentiality. The orthodontist will review your medical history and explain any questions that you do not understand.

  • Are you being treated for any medical condition at this time or have you been treated for a medical condition within the past two years?YesNo
  • When was your last medical check-up?
  • Has there been a change in your health within the past two years? YesNo
  • Are you currently taking any medications, non-prescription drugs, or herbal supplements? YesNo
  • Do you have any allergies? If yes, please list using the categories below: YesNo
  • Do you ever have an adverse reaction to any medications, injections or anaesthetics? YesNo
  • Have you ever had your adenoids and/or tonsils removed? YesNo
  • Have you ever been diagnosed with asthma? YesNo
  • Have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e., infective endocarditis), a heart condition from birth (i.e., congenital heart disease) or a heart transplant?
    YesNo
  • Do you have a prosthetic or artificial joint? YesNo
  • Do you have any conditions or therapies that could affect your immune system (e.g., leukemia, AIDS, HIV, radiotherapy, chemotherapy)? YesNo
  • Have you ever had hepatitis, jaundice or a liver disorder? YesNo
  • Do you have a bleeding problem or bleeding disorder? YesNo
  • Have you ever been hospitalized for any illnesses or operations? YesNo
  • Have you ever been diagnosed with the following?
    AnemiaRheumatoid ArthritisArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease
  • Are there any conditions or diseases not listed above that you have had? YesNo
  • Women: Are you breastfeeding or pregnant? YesNo
  • If pregnant, what is the expected delivery date?

DENTAL HISTORY

  • Are you nervous during dental treatment? YesNo
  • Are you a mouth breather while sleeping or awake (or both)? YesNo
  • Have you ever had a habit such as thumb or finger sucking, nail biting, lip sucking, grinding teeth, or an unusual swallow pattern? YesNo
  • Have you ever been informed of any missing or extra permanent teeth? YesNo
  • Have there been any injuries to your face, mouth, or teeth? YesNo
  • Have you experienced any jaw joint noises, jaw joint pain, or limited jaw movement? YesNo
  • Have you previously consulted an orthodontist? YesNo
  • Has any member of your family had orthodontic treatment? YesNo

PATIENT CONSENT FOR THE COLLECTION, USE AND DISCLOSURE OF YOUR PERSONAL HEALTH INFORMATION

Privacy of your personal health information is an important part of our office's providing you with quality dental care. We understand the importance of protecting your personal health information. We are committed to collecting, using and disclosing your personal health information responsibly. We also try to be as open and transparent as possible about the way we handle your personal health information. It is important to us to provide this service to our patients.
In this office, Dr. John A. Todd is the contact person for personal health information related matters. All staff members who come into contact with your personal health information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.

Please click here for an outline of what our office is doing to ensure that

  • Only necessary information is collected about you.
  • We only share your information with your consent.
  • Storage, retention and destruction of your personal health information complies with existing legislation, and privacy protection protocols.
  • Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons or Ontario, and the law.

Do not hesitate to discuss our policies with Dr. Todd or any member of our office staff. By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health information, we will seek your approval in advance.

Your personal health information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA.

You may withdraw your consent for use or disclosure of your personal health information at any time.
I have reviewed the above information that explains how your office will use my personal health information, and the steps that your office if taking to protect my information. I agree that Dr. John A. Todd Dentistry Professional Corporation can collect, use and disclose personal health information as set out above in the information about the office’s privacy policies.

    AUTHORIZATION


Serving: Kingston, Napanee, Gananoque, Sydenham, Amherstview, Barriefield, Sharbot Lake, Westport, Perth, Ernestown, Harrowsmith, Tamworth, Seeley’s Bay, Lansdowne, Elgin, Crosby, Arden, Odessa, Glenburnie, Elginburg, and Westbrook.

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