Full Medical History - 7Dental

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Appointment Request

Request Appointment

Location Information
Please choose the Location(s) you wish to attend:*
- Central Park
- Blossom Park
- Findlay Creek
- Tenth Line
- Trim Social
- Knata South
- Any Location
Patient information
Your Name:*
First Last
Date of birth:*
YYYY dash MM dash DD
Sex:*
Your Email:*
Phone*
Is this a mobile number ?*
- Yes
- No
Are you already a patient of 7Dental?*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Current 7Dental Location:*
What type of appointment would you like?
- Complete Oral Exam
- Dental Cleaning & Checkup
- Denture Consult
- Ortho Consultation
- Invisalign™ Free Smile Assessment
- Other
type of appointment would you like:
How did you hear about us?

Appointment Request

Request Appointment

Location Information
Please choose the Location(s) you wish to attend:*
- Central Park
- Blossom Park
- Findlay Creek
- Tenth Line
- Trim Social
- Knata South
- Any Location
Patient information
Your Name:*
First Last
Date of birth:*
YYYY dash MM dash DD
Sex:*
Your Email:*
Phone*
Is this a mobile number ?*
- Yes
- No
Are you already a patient of 7Dental?*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Current 7Dental Location:*
What type of appointment would you like?
- Complete Oral Exam
- Dental Cleaning & Checkup
- Denture Consult
- Ortho Consultation
- Invisalign™ Free Smile Assessment
- Other
type of appointment would you like:
How did you hear about us?

ABOUT
LOCATIONS
SERVICES
INVISALIGN
SPECIALTIES
PATIENTS
FORMS

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ABOUT
LOCATIONS
SERVICES
INVISALIGN
SPECIALTIES
PATIENTS
FORMS

Appointment Request

Request Appointment

Location Information
Please choose the Location(s) you wish to attend:*
- Central Park
- Blossom Park
- Findlay Creek
- Tenth Line
- Trim Social
- Kanata South
- Any Location
Patient information
Your Name:*
First Last
Date of birth:*
YYYY dash MM dash DD
Sex:*
Your Email:*
Phone*
Is this a mobile number ?*
- Yes
- No
Are you already a patient of 7Dental?*
- Yes
- No
Address
Street Address Address Line 2 City Province Postal Code
Current 7Dental Location:*
What type of appointment would you like?
- Complete Oral Exam
- Dental Cleaning & Checkup
- Denture Consult
- Ortho Consultation
- Invisalign™ Free Smile Assessment
- Other
type of appointment would you like:
How did you hear about us?
Recaptcha

Dental Emergency

ABOUT
LOCATIONS
SERVICES
INVISALIGN
SPECIALTIES
PATIENTS
FORMS

1Patient Information

2Patient Medical History

3Patient Dental History

4Signature Page

Patient Information
Hidden
Date (yyyy-mm-dd)
YYYY dash MM dash DD
Name:*
First Last
Preferred name / nickname:
Date Of Birth (yyyy-mm-dd):*

Year
Month
Day
Sex:*
Mobile Phone:*
Email:
Other Phone:
Address:*
Street Address Address Line 2 City Province Postal Code
Employer:
Occupation:
Work Phone:
Whom may we thank for referring you?*
First
First
Emergency Contact:
First Last
Relationship:
Phone:
Person responsible for payments:*
- Patient
- Another person
Person responsible for payments: Patient
Person responsible for payments:*
First Last
Relationship:*
Is this person a patient at 7Dental?*
- Yes
- No
Address:
- Same as Patient's address above
Address is same as Patient's address above
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mobile Phone:*
Email:*
Other Phone:

Patient Medical History
Family Physician’s Name:
First
Family Physician’s Phone Number:
Date of last physician exam:
Are you under medical treatment now?*
- Yes
- No
Comments:
Do you presently have any general health concerns?*
- Yes
- No
Comments:
Have you ever been hospitalized for any surgical operations or any illnesses?*
- Yes
- No
Comments:
Are you taking any medication (s) including non-prescription medicine?*
- Yes
- No
Comments:
Do you smoke or chew tobacco?*
- Yes
- No
Comments:
Do you have any allergies to medications / others?*
- Yes
- No
Comments:
Do you have or have you had any of the following?
High Blood Pressure*
- Yes
- No
Heart Murmur*
- Yes
- No
Hepatitis/jaundice*
- Yes
- No
Low Blood Pressure*
- Yes
- No
Thyroid problem*
- Yes
- No
Liver disease*
- Yes
- No
Heart Attack*
- Yes
- No
Heart disease*
- Yes
- No
Sexually transmitted disease*
- Yes
- No
Rheumatic Fever*
- Yes
- No
Cardiac pacemaker*
- Yes
- No
Stomach troubles/ulcer*
- Yes
- No
Fainting/Seizures*
- Yes
- No
Chest pains/Angina*
- Yes
- No
Stroke*
- Yes
- No
Asthma*
- Yes
- No
Anemia*
- Yes
- No
Hay fever/allergies*
- Yes
- No
Epilepsy/Convulsion*
- Yes
- No
Emphysema*
- Yes
- No
Tuberculosis*
- Yes
- No
Leukemia*
- Yes
- No
Respiratory problem*
- Yes
- No
Radiation therapy*
- Yes
- No
Diabetes*
- Yes
- No
Cancer*
- Yes
- No
Glaucoma*
- Yes
- No
Kidney disease*
- Yes
- No
Arthritis*
- Yes
- No
Recent weight loss*
- Yes
- No
AIDS or HIV infection*
- Yes
- No
Joint Replacement or implant*
- Yes
- No
Others*
- Yes
- No
Comments
Are you pregnant or think you may be pregnant?
- Yes
- No
Are you taking birth control pills?
- Yes
- No

Patient Dental History
Please choose the comments that pertain to you:
I brush my teeth:*
I floss my teeth:*
- My gums bleed while brushing or flossing
- I feel pain in one or more of my teeth
- I have had head, neck or jaw injury
- I have had Orthodontic (braces) work done
- My jaw sometimes clicks
- I have jaw pain (jaw joint, ear, or side of the face)
- I clench my teeth
- I have difficulty in opening or closing my mouth
- I experience difficulty in chewing
- I get frequent headaches
- I feel I have bad breath
- I am dissatisfied with the colour of my teeth
- I am unhappy with the appearance of my smile
- I have never had professional instructions on the care of my gums
Do you have any other concerns about your teeth or smile?
- Yes
- No
Comments ...
Previous Dentist Name:
Date of Last Dental Visit:

Once you press submit, we will receive a PDF copy of the completed form and have it ready for you to sign at your next visit to the clinic.
Patient/Guardian:*
First Last
______________________
Patient/Guardian Signature ______________________
Dentist Signature ______________________
Date ______________________
Admin Name
______________________
Patient/Guardian Signature ______________________
Dentist Signature ______________________
Date ______________________
Admin Name
______________________
Patient/Guardian Signature ______________________
Dentist Signature ______________________
Date ______________________
Admin Name
______________________
Patient/Guardian Signature ______________________
Dentist Signature ______________________
Date ______________________
Admin Name

Dental emergency? Call us!

613-7DENTAL ( 733-6825 )

Appointment Request

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+1-613-733-6825
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