Demographic Information

PATIENT INFORMATION
Prefix
Mr.Mrs.Ms.Dr.

Name

Sex

Date of Birth / Age

Email

Mailing Address

Best Contact Tel. / Other Contact Tel.

Have you ever been a patient of our practice?
YesNo

Dentist

Orthodontist

Medical Dr.

Preferred Pharmacy / Tel.

In case of emergency, please contact

Emergency Tel. / Relation

WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT:

If Other, give description

Who will be responsible for your account
Name

Email

Best Contact Tel. / Other Contact Tel.

Insurance Information

PRIMARY DENTAL INSURANCE COMPANY:
Ins. Co. Name

I.D. # / Cert. #

Group # / Contract

Policy Holder

Policy Holder's DOB

SECONDARY DENTAL INSURANCE COMPANY:
Ins. Co. Name

I.D. # / Cert. #

Group # / Contract

Policy Holder

Policy Holder's DOB

CANADIAN MEDICAL INSURANCE:
Province / Health Care #

Health History

HEALTH HISTORY:
To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Reason for today's office visit?

Height / Weight

Are you in good health?
YesNo

Have there been any changes in your general health in the past year?
YesNo

Are you under the care of a physician?
YesNo

Have you had any illness, operation or been hospitalized in the past five years?
YesNo

Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?
YesNo

Do you have a prosthetic joint/implant?
YesNo

Have you had a heart valve replacement or vascular graft?
YesNo

Have you ever had general anesthesia?
YesNo

Have you, or a family member, had any unusual or serious reactions to general anesthesia?
YesNo

If so, what was the reaction?

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
YesNo

Are you currently taking, or have taken in the past, bisphosphonate medications for bone health or pain?
YesNo

Health History Part 2

HAVE YOU HAD, OR DO YOU CURRENTLY HAVE:
Rheumatic fever?
YesNo

Damaged heart valves / mitral valve prolapse?
YesNo

Heart murmur?
YesNo

High blood pressure?
YesNo

Low blood pressure?
YesNo

Chest pain / angina?
YesNo

Heart attack(s)?
YesNo

Irregular heart beat?
YesNo

Cardiac pacemaker?
YesNo

Heart surgery?
YesNo

Pneumonia, bronchitis or chronic cough?
YesNo

Asthma?
YesNo

Hay fever / sinus problems?
YesNo

Snoring?
YesNo

Sleep Apnea / CPAP?
YesNo

Difficult breathing / other lung trouble?
YesNo

Tuberculosis?
YesNo

Emphysema?
YesNo

Do you smoke?
YesNo

Do you vape?
YesNo

Do you use marijuana?
YesNo

Do you use recreational drugs?
YesNo

If so, how often / how much?

Do you use chewing tobacco?
YesNo

Blood transfusion?
YesNo

Blood disorder such as anemia?
YesNo

Bruise easily?
YesNo

Bleeding tendency / abnormal bleed?
YesNo

Hepatitis, jaundice, or liver disease?
YesNo

Infectious mononucleosis?
YesNo

Gallbladder trouble?
YesNo

HAVE YOU HAD, OR DO YOU CURRENTLY HAVE:
Fainting spells?
YesNo

Convulsions / epilepsy?
YesNo

Stroke?
YesNo

Thyroid trouble
YesNo

Diabetes?
YesNo

Low blood sugar?
YesNo

Kidney trouble?
YesNo

High cholesterol?
YesNo

Are you on dialysis?
YesNo

Swollen ankles / arthritis / joint disease?
YesNo

Osteoporosis / osteopenia?
YesNo

Osteonecrosis?
YesNo

Stomach ulcers / acid reflux?
YesNo

Contagious diseases?
YesNo

Sexually transmitted diseases?
YesNo

Problems with the immune system? Possibly from medication / surgery, etc?
YesNo

Delay in healing?
YesNo

A tumor or growth?
YesNo

Cancer / radiation therapy /chemotherapy?
YesNo

Chronic fatigue / night sweats?
YesNo

Are you on a diet?
YesNo

A history of alcohol abuse?
YesNo

A history of marijuana or other drug use?
YesNo

Contact lenses?
YesNo

Eye disease / glaucoma?
YesNo

Mental health problems / anxiety / depression?
YesNo

Please elaborate on your health history if applicable:

WOMEN ONLY:
Is there a possibility of pregnancy?

Expected delivery date

Are you nursing?

Are you taking birth control pills?

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.

Medications / Allergies

ARE YOU NOW TAKING:
Blood thinners?
YesNo

Have you ever taken diet pills?
YesNo

Any natural product, herbal supplement or homeopathic remedy?
YesNo

Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphos-phonates in the past 12 years?
YesNo

Have you ever taken tranquilizers, sleeping pills, anti-depressants and/or narcotics on a regular basis. If yes, please list:

If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:

Methadone?
YesNo

Suboxone?
YesNo

Oxycodone?
YesNo

Fentanyl?
YesNo

Other
YesNo

ARE YOU ALLERGIC TO, OR HAD A REACTION TO:
Local anesthetic (freezing)?
YesNo

Penicillin / amoxicillin?
YesNo

Sulfa Drugs?
YesNo

Clindamycin?
YesNo

Aspirin / ibuprofen?
YesNo

Other antibiotics?
YesNo

Codeine or other narcotics?
YesNo

Latex?
YesNo

Please list any other allergies:

Are you taking any kind of medication, drug, pills?
YesNo

PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING:
Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Medication #11

Medication #12

Medication #13

Medication #14

Medication #15

Conclusion

Conclusion
If you are having surgery today under sedation, have you had anything to eat or drink in the last 8 hours?
YesNo

If you are being seen for surgery under sedation, who is driving you home?

Is there any condition concerning your health that the Doctor should be told about?
YesNo

If Yes, describe

Do you wish to speak to the Dr. privately about anything?
YesNo

Is there a family history of:
CancerDiabetesHeart diseaseAnesthesia problems

Accident History
Is this visit related to an accident?
YesNo

If Yes, what type of accident?
AutomobileWork relatedOther

Date of Injury

Insurance company handling the claim / Claim #

Name of attorney / adjustor

Telephone number

Verification

VERIFICATION, FEES & PAYMENT, AND AUTHORIZATION
Verification
I certify that I have read and I understood the questions above. I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I will not hold my doctor, or any member of the staff at Kelowna Oral & Facial Surgery, responsible for any errors or omissions that I have made in the completion of this form.

If I have chosen to have sedation or general anesthesia as part of my surgery today, I certify that I have not had anything to eat or drink in the past 8 (eight) hours.


Fees and Payments
Payment is due in full at the time treatment is rendered. An estimate of the costs for any procedure or surgery you may require will be provided to you. If you have dental insurance we will be glad to fill out the claim forms on your behalf, and you will be reimbursed directly according to your insurance plan.

This signature on file is my authorization for the release of information necessary to process my claim.


Authorization
I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x–rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile device concerning my care.


Signature of patient (Parent or Guardian if Minor)