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ADDRESS:
805 DEVELOPMENT DR, KINGSTON, ON K7M 4W6
TEL: 613-389-8660
EMAIL: reception@davidgouettdentistry.com
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Medical History Wisdom Teeth
Official Clinical Data Record Submission
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Name
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[Full Legal Name]
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Street Address
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[Street Address]
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City
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[City]
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Postal Code
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[Postal Code]
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Date of Birth
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[mm/dd/yyyy]
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Home
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[000-000-0000]
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Cell
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[000-000-0000]
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Health Card Number
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[0000-XX]
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General Health Assessment
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1. Are you having pain or discomfort at this time?
Response: [YES/NO]
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2. Do you feel very nervous about having dental
treatment?
Response: [YES/NO]
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3. Have you ever had a bad experience in the
dental office?
Response: [YES/NO]
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4. Have you been a patient in the hospital during
the past two years?
Response: [YES/NO]
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5. Have you been under the care of a medical
doctor in the past two years?
Response: [YES/NO]
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6. Have you taken any medicine or drugs during the
past two years?
Response: [YES/NO]
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7. Are you allergic to (itching, rash, swelling of
hands, feet or eyes) or made sick by penicillin,
aspirin, codeine, or any other drug or medication?
Response: [YES/NO]
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Medications
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[Patient's Response / List of medications]
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8. Have you ever had any excessive bleeding
requiring special treatment?
Response: [YES/NO]
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Reported Health Conditions Present:
• Rheumatic Fever
• Anemia
• Sinus Trouble
• [Other Selected Conditions]
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Physical Wellness Indicators
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9. When you walk up stairs or take a walk do you
ever have to stop because of pain in our chest,
shortness of breath or because you are very tired?
Response: [YES/NO]
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10. Do your ankles swell during the day?
Response: [YES/NO]
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11. Do you use more than 2 pillows to sleep?
Response: [YES/NO]
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12. Have you lost or gained more than 10 pounds in
the past year?
Response: [YES/NO]
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13. Do you ever wake up from sleep short of
breath?
Response: [YES/NO]
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14. Are you on a special diet?
Response: [YES/NO]
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15. Has you medical doctor ever said you have
cancer or a tumor?
Response: [YES/NO]
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16. Do you have any disease, condition or problem
not listed?
Response: [YES/NO]
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Details
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[Patient's Explanation]
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Women Only
Are you pregnant?
Response: [YES/NO]
Do you anticipate becoming pregnant?
Response: [YES/NO]
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TO THE BEST OF MY KNOWLEDGE, ALL OF THE PRECEDING
ANSWERS ARE TRUE AND CORRECT. IF I EVER HAVE ANY
CHANGE IN MY HEALTH, OR IF MY MEDICATION CHANGES,
I WILL INFORM THE DOCTOR AT THE NEXT APPOINTMENT
WITHOUT FAIL.
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Digital Signature Record
[Digitally Endorsed by Patient]
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Date Signed
[mm/dd/yyyy]
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Financial Agreement Summary
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Insurance Carrier:
[Carrier Name]
Policy Holder:
[Name and DOB]
Policy / Cert #:
[Contract Info]
* A Charge of $75.00 for less than 48 hours'
notice of cancellation appointment applies.
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Gouett Dentistry
Architectural Excellence in Restorative Care.
Systems Nominal & ISO 9001 Certified Clinical
Environment.
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