Brookswood Denture Clinic
Returning Patient Medical History
Patient Name
*
First
Last
Date of birth
*
MM slash DD slash YYYY
Home Phone
Cell Phone
Family Doctor
*
Dentist
*
Do you have dental insurance?
*
Yes
No
Has your dental insurance changed?
*
Yes
No
Do you have or have had any of the following:
Alzheimer/Dementia
Asthma
Anemia
Arthritis
Blood disorder
Cancer
Hepatitis A B C
Radiation Treatment
Cholesterol
COPD
Diabetes
Epilepsy
HIV or Aids
Head or Neck Injury
High or low blood pressure
Heart condition
Kidney problems
Liver problems
MRSA
Migraines/headaches
Osteoporosis
TMJ disorder
Rheumatic Fever
Sinus problems
Tuberculosis
Thyroid problems
Visually Impaired
None
Are you taking any prescription/non-prescription medications?
*
Yes
No
Please list or bring a copy to your appointment.
Have you had significant weight loss?
*
Yes
No
Do you get food under your dentures?
*
Yes
No
My Upper denture is loose
Yes
No
My Lower denture is loose
Yes
No
Do you use store bought adhesives?
*
Yes
No
Do you chew well with your dentures?
*
Yes
No
Do you have gum pain or ulcers?
*
Yes
No
Do you experience dry mouth?
*
Yes
No
Do you chew mints or gum?
*
Yes
No
Do you bleed or bruise easily?
*
Yes
No
Do you grind or clench your teeth?
*
Yes
No
Do you smoke?
*
Yes
No
Do you have hearing issues?
*
Yes
No
Do you have memory issues?
*
Yes
No
Do you have allergies to any of the following:
*
Select All
Latex Gloves
Metals
Plastics
None
Do you have any other allergies?
If you have any natural teeth remaining, when was your last visit with a dentist?
What are your concerns with your current dentures?
*
Consent
Consent
*
I certify that the medical and dental information I provided is accurate to the best of my knowledge.
*
Consent
*
I consent to have treatment at Brookswood Denture clinic and this consent will apply to each appointment I need to complete treatment.
*
Consent
*
I understand that I may be seeing my denturist several times to complete denture treatment and it is not possible to maintain social distancing of 2 metres (6 feet).
*
Consent
*
I assume responsibility for all fees incurred. All fees not covered by my insurance company will be my responsibility.
*
Name of person filling out this form
First
Last
Phone
Signature
Email
This field is for validation purposes and should be left unchanged.
Brookswood Denture Clinic
20103 40th Avenue
102
LANGLEY, British Columbia V3A 2W3
604-530-9936
[email protected]