Downstream Dental
Professional dental care for you and your family
Home
Gallery
Meet Our Team
Services
Preventative Dentistry
Restorations
Tooth Extractions
Dental Implants
Root Canals
Invisalign
Dental Emergencies
Tongue/Lip Tie Release
Forms
Resources
Contact Us
☎︎ (250) 338-6263
Downstream Dental
Professional dental care for you and your family
Home
Gallery
Meet Our Team
Services
Preventative Dentistry
Restorations
Tooth Extractions
Dental Implants
Root Canals
Invisalign
Dental Emergencies
Tongue/Lip Tie Release
Forms
Resources
Contact Us
☎︎ (250) 338-6263
Patient Forms
Name
Name
MSP CareCard No.
MSP CareCard No.
Date of Birth
Date of Birth
MM
DD
YYYY
Gender
Gender
Male
Female
Height
Height
Weight
Weight
BMI
BMI
Residential Phone
Home Phone
(###)
###
####
Cell Phone
Cell Phone
(###)
###
####
Work Phone
Work Phone
(###)
###
####
Home Address
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Email
Email contact ok
Email contact ok?
Yes
No
Emergency Contact
Emergency Contact
Emergency Contact Name
Emergency Contact Relation
Emergency Contact Relation
Emergency Contact Telephone
Emergency Contact Phone
(###)
###
####
Parent or legally authorized representative
Other Contacts
Name of parent or legally authorized representative (if applicable)
Physician's Name
Name of physician
Dental History
Dental History
Place a check beside items that describe your past dental problems and dental care.
Regular dental care
Wisdom tooth extractions
Gum disease (pyorrhea, gingivitis or periodontal disease)
Treatment for jaw trauma/fracture (please describe below)
Had an adverse reaction for dental treatment (please describe below)
Orthodontics
Dental fears or anxiety
Jaw trauma/fracture type
Please describe type of jaw trauma/fracture, if checked above.
Adverse reaction description
Please describe adverse reaction for dental treatment, if checked above.
Treated at present or within past year
Medical History Questionnaire
Are you being treated for any medical condition at present or within the past year? Changes in general health? If yes, please describe below.
Yes
No
Present Treatment/Changes in Medical Condition
Hospitalized in last five years
Have you been hospitalized in the last five years? If yes, please describe below.
Yes
No
Hospitalization in past 5 years
Drugs, vitamins or herbal supplements
Are you taking any prescription or non-prescription drugs, vitamins or herbal supplements? If yes, please describe below.
Yes
No
Drugs, vitamins or herbal supplements description
Sensitivities or allergies
Do you have any sensitivities or allergies? If yes, please describe below.
Yes
No
Sensitivities or allergies description
History of family disease
Do you have any history of family disease? If yes, please describe below.
Yes
No
History of family disease description
Last visit to physician
When was your last visit to a physician?
Last complete medical examination
Date of last complete medical examination?
Do you or have you had
Do you or have you had: (please check)
Alzheimers
Anemia
Angina pectoris
Arthritis/rheumatism
Artificial heart valve
Artificial joints
Asthma
Balance problems
Bleed easily
Blood disorders
Bronchitis
Cancer
Cerebral palsy
Chest pains
Circulation problems
Congenital heart lesions
Cogestive heart failure
Cortisone/steroid therapy
Diabetes
Earaches (frequent)
Emphysema
Epilepsy or seizures
Fainting or dizzy spells
Glandular disorders
Glaucoma
Headaches (severe)
Head/neck injuries
Hearing difficulties
Heart disease or attack
Heart murmur
Heart pacemaker
Heart rhythm disorder
Heart surgery
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
Herpes
Hodgkin’s disease
Hyper(hypo) glycemia
Hypertension
Impaired vision
Infective endocarditis
Jaundice
Kidney disease
Leukemia
Liver disease
Lung disease
Malignant hyperthermia
Medical implant
Mental/nervous disorder
Mitral valve prolapse
Nosebleeds (frequent)
Organ transplant
Persistent cough
Pulmonary edema
Positive testing for HIV
Psychiatric treatment
Radiation treatment
Chemotherapy
Rheumatic/scarlet fever
Sinus trouble
Shortness of breath
Sleep apnea
Stomach/intestinal problems
Stroke
Thyroid disease
TMJ
Tuberculosis
Ulcers
Venereal disease
Weight gain/loss
Smoke or other forms of tobacco
Do you smoke or use other forms of tobacco?
Yes
No
Alcohol and/or drug use
Do you have a history of alcohol and/or drug use?
Yes
No
Street or recreational drugs
Currently using any street or recreational drugs? If yes, please describe below.
Yes
No
Street or recreational drugs type
Number of carbonated beverages a day
Number of carbonated beverages a day
0
1-2
3-5
5+
Disease, condition or problem not listed above
Do you currently have, or have you had in the past, any disease, condition or problem not listed above? If yes, please describe below.
Yes
No
Disease, condition or problem not listed above description
Problem or medical condition to discuss in private only
Is there any problem or medical condition that you wish to discuss in private only?
Yes
No
Pregnant or suspect you might be
WOMEN ONLY: Are you pregnant or suspect you might be? If yes, please enter your anticipated delivery date below.
Yes
No
Anticipated delivery date
Breast feeding
WOMEN ONLY: Are you breast feeding?
Yes
No
Birth control pills
WOMEN ONLY: Are you taking any birth control pills?
Yes
No
Signature
NOTE: IT IS IMPORTANT THAT ANY CHANGES IN YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE.
I the undersigned, certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician, pharmacist or insurance provider being contacted if necessary to obtain information that is required for my dental care. Signature
Signed Date
Date
Signed by
Signed by
Patient
Parent
Legally Authorized Representative
Thank you! Your form has been submitted.