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49 Colborne St Lower Level Toronto, ON M5E 1C6
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Dental Referral Form
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Dental Referral Form
Medical History Form (Adult)
Fill in necessary information below.
Date
*
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Name
*
First
Last
I prefer to be called
*
Social Insurance Number
*
Birth Date
*
Month
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1921
1920
Sex
*
Male
Female
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Home Address
*
City, State, Zip code
*
Home Phone
Cellphone
Work Phone
Email
Occupation
*
Employer
*
Close Relative
Spouse or closest relative's name(s)
*
Relationship
*
Address (if different from patient address)
Home Phone
Cellphone
Work Phone
Dentist
Patient's Dentist
Address, City, State
Last Seen
Reason
Next Appointment
Other dentists/dental specialist now being seen
Reason
City, State
Physician
Patient's Physician
Address, City, State
Last seen
Reason
Next Appointment
Most recent physical exam
Other physicians/health care providers being seen now
Name
Address, City, State
Reason
Name
Address, City, State
Reason
GENERAL INFORMATION
What concerns you about your teeth?
*
Who suggested that you might need orthodontic treatment?
Why did you select our office?
Have you any previous orthodontic treatment? Please describe
Have any other family members been treated in this office? Please name them.
Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.
FINANCIAL RESPONSIBILITIES
Who is financially responsible for this account?
*
Address
*
City, State, Zip code
*
Home Phone
Cellphone
Work Phone
Social Security Number
*
Employer
Who will be responsible for bringing the patient to orthodontic appointments?
*
DENTAL INSURANCE
Primary policy holder's full name
*
Birth Date
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
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11
12
13
14
15
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18
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20
21
22
23
24
25
26
27
28
29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
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1972
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1969
1968
1967
1966
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1964
1963
1962
1961
1960
1959
1958
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1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Social Security Number
*
Relationship to patient
*
Address (if not listed above)
Phone (if not listed above)
Employer
Address
Insurance company
Group Number
ID Number
Does this policy have orthodontic benefits?
Yes
No
I don't know
Secondary policy holder's full name
Birth Date
Month
1
2
3
4
5
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7
8
9
10
11
12
Day
1
2
3
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5
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14
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16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Social Security Number
Relationship to patient
*
Address (if not listed above)
Phone (if not listed above)
Employer
Address
Insurance company
Group Number
ID Number
Does this policy have orthodontic benefits?
Yes
No
I don't know
MEDICAL INSURANCE
Policy holder's full name
Insurance company
Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions mark yes, no or don't know/understand(dk/u).
MEDICAL HISTORY
Now or in the past, have you had Birth defects of hereditary problems?
*
Yes
No
Don't know
Bone fractures, or major injuries?
*
Yes
No
Don't know
Any injuries to face, head, neck?
*
Yes
No
Don't know
Arthritis or joint problems?
*
Yes
No
Don't know
Endocrine or thyroid problems?
*
Yes
No
Don't know
Diabetes or low sugar?
*
Yes
No
Don't know
Kidney problems?
*
Yes
No
Don't know
Cancer, tumor, radiation treatment or chemotheraphy?
*
Yes
No
Don't know
Stomach ulcer, hyperacidity, acid reflux?
*
Yes
No
Don't know
Immune system problems?
*
Yes
No
Don't know
History of osteoporosis?
*
Yes
No
Don't know
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
*
Yes
No
Don't know
AIDS or HIV positive?
*
Yes
No
Don't know
Hepatitis, jaundice or other liver problem?
*
Yes
No
Don't know
Polio, mononucleosis, tuberculosis, pneumonia?
*
Yes
No
Don't know
Seizure, fainting spells, neurologic problem?
*
Yes
No
Don't know
Mental health disturbance or depression?
*
Yes
No
Don't know
Vision, hearing, or speech problem?
*
Yes
No
Don't know
History of eating disorder (anorexia, bulimia)?
*
Yes
No
Don't know
High or low blood pressure?
*
Yes
No
Don't know
Excessive bleeding or bruising, anemia?
*
Yes
No
Don't know
Chest pain, shortness of breath, tire easily, swollen ankles?
*
Yes
No
Don't know
Heart defects, heart murmur, rheumatic heart disease?
*
Yes
No
Don't know
Angina, arteriosclerosis, stroke or heart attack?
*
Yes
No
Don't know
Skin disorder (other than common acne)?
*
Yes
No
Don't know
Do you eat a well-balanced diet?
*
Yes
No
Don't know
Frequent headaches or migraines?
*
Yes
No
Don't know
Frequent ear infections, colds, throat infections?
*
Yes
No
Don't know
Asthma, sinus problems, hayfever?
*
Yes
No
Don't know
Tonsil r adenoid condition?
*
Yes
No
Don't know
Do you frequently breath through your mouth?
*
Yes
No
Don't know
DENTAL HISTORY
Now or in the past, have you had Permanent or extra (supernumerary) teeth removed?
*
Yes
No
Don't know
Supernumerary (extra) or congenitally missing teeth?
*
Yes
No
Don't know
Chipped or injured primary or permanent teeth?
*
Yes
No
Don't know
Any sensitive or sore teeth?
*
Yes
No
Don't know
Bleeding gums, bad taste or mouth odor?
*
Yes
No
Don't know
Jaw fractures, cysts, infections?
*
Yes
No
Don't know
Any teeth treated with root canals or pulpotomies?
*
Yes
No
Don't know
"Gum boils," frequent canker sores or cold sores?
*
Yes
No
Don't know
History of speech problems or speech therapy?
*
Yes
No
Don't know
Difficulty breathing through nose?
*
Yes
No
Don't know
Food impaction between the teeth?
*
Yes
No
Don't know
Mouth breathing habit or snoring at night?
*
Yes
No
Don't know
History of speech problems?
*
Yes
No
Don't know
Frequent oral habits (sucking finger, chewing pen, etc.)?
*
Yes
No
Don't know
Teeth causing irritation to lip, cheek or gums?
*
Yes
No
Don't know
Abnormal swallowing (tongue thrust)?
*
Yes
No
Don't know
Tooth grinding or clenching?
*
Yes
No
Don't know
Clicking, locking in jaw joints?
*
Yes
No
Don't know
Soreness in jaw muscles or face muscles?
*
Yes
No
Don't know
Ringing in ears, difficulty in chewing or opening jaw?
*
Yes
No
Don't know
Have you ever been treated for "TMJ" or "TMD" problems?
*
Yes
No
Don't know
Any broken or missing fillings?
*
Yes
No
Don't know
Any serious trouble associate with previous dental treatment?
*
Yes
No
Don't know
Have you ever been diagnosed with gum disease or pyorrhea?
*
Yes
No
Don't know
Have you ever had an orthodontic consultation or treatment before now?
*
Yes
No
Don't know
Have you had allergies or reactions to any of the following:
Local anesthetics (novocaine, lidocaine, xylocaine)
*
Yes
No
Don't know
Latex (gloves, ballons)
*
Yes
No
Don't know
Aspirin
*
Yes
No
Don't know
Ibuprofen (Motrin, Advil)
*
Yes
No
Don't know
Penicillin
*
Yes
No
Don't know
Other antibiotics
*
Yes
No
Don't know
Metals (jewelry, clothing snaps)
*
Yes
No
Don't know
Acrylics
*
Yes
No
Don't know
Plant pollens
*
Yes
No
Don't know
Animals
*
Yes
No
Don't know
Foods
*
Yes
No
Don't know
Other substances
*
Yes
No
Don't know
PATIENT HEALTH INFORMATION
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.
Medication
Taken for
Have you ever taken any medications to strengthen your bones? Please describe.
Do you take antibiotic pre-medication before any dental procedures?
Yes
No
Do you or have you ever had a substance abuse problem?
Yes
No
Do you chew or smoke tobacco?
Yes
No
Have you noticed any changes in your face or jaws?
Any other physical problems?
How often do you brush?
How often do you floss?
Women: Are you pregnant?
*
Yes
No
Are you trying to become pregnant?
*
Yes
No
FAMILY MEDICAL HISTORY
Have your parents or siblings ever had any of the following health problems? If so, please explain.
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
RELEASE AND WAIVER
I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.
Signature
*
Date
*
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
Signature
*
Date
*
MEDICAL HISTORY UPDATES OR CHANGES
Changes
Patient Signature
Date
Changes
Patient Signature
Date
Changes
Patient Signature
Date
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