Patient Medical History for General Consultations Step 1 of 6 16% Full Name*Date of Birth (dd/mm/yyyy)*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Telephone*Cell PhoneBest Number to Contact You*Email* Marital StatusEmployerOccupationEmergency Contact Name*Relationship*Emergency Contact Phone Number*General Dentist Name*How did you hear about us? (Dentist, Hygienist, Friend, etc.)Do you have dental insurance?* Yes No Family Physician NamePhone Number (if known)PharmacyPhone Number (if known)When was your last physical exam?*Would you consider yourself to be in good health? Yes No Has there been any change in your health in the last year? Yes No If yes, please elaborate:Have you received the Covid-19 vaccine? Yes - Fully Vaccinated Yes - Partially Vaccinated No, but I may opt to receive it No, with no intention to receive it Prefer not to answer Has it ever been recommended that you routinely have antibiotic coverage before surgery or dental treatment?* Yes No Are you allergic to or have you ever reacted adversely to any of the following?* Aspirin Penicillin Tetracycline Other Antibiotics Codeine or other narcotics Sedatives or sleeping pills Local anesthetics Latex Gloves Other None of the Above Other Allergies (please list)Do you smoke cigarettes?* Yes No If so, how many cigarettes/day?How many years have you smoked?Are you a former smoker?* Yes No If so, how many cigarettes/day?How many years did you smoke?How long ago did you quit?Do you smoke cannabis?* Yes No If so, how often?Do you drink alcohol?* Yes No If so, how many servings per week?On a scale of 1 to 5, what is your level of stress?* 1 - less than average 2 3 - average level of stress 4 5- more than average On a scale of 1 to 5, how healthy is your diet?* 1 - consistently unhealthy diet 2 3 - somewhere in the middle 4 5- consistently healthy diet Do you have or have you had any of the following conditions? Check all that apply* High Blood Pressure Heart Trouble Mitral Valve Prolapse (MVP) Angina Pectoris Heart Murmur Artificial Heart Valve Heart Surgery Heart Attack Artificial Joint Stomach Ulcer Sleep Apnea Stroke Glaucoma Liver Disease Anemia Hepatitis A/B/C Excessive Bruising Yellow Jaundice Thyroid Disease Leukemia Hemophilia or Blood Transfusion Kidney Trouble HIV (AIDS) Venereal Disease Cold Sores Emphysema/Bronchitis Persistent Cough Asthma Tuberculosis Drug Addiction Alcohol Dependency Hayfever Sinus Troubles Fainting Eating Disorders Psychiatric Treatment Diabetes or Excessive Thirst Arthritis Osteoporosis Cancer Epilepsy/Seizures Rheumatic or Scarlet Fever None of the Above Have you ever been hospitalized? If so, why?Are there any medical conditions that run in your family? (i.e., high blood pressure, diabetes, cancer)Have you ever had abnormal bruising or bleeding associated with previous extractions, surgery, or injuries?Have you ever had any serious trouble with any previous dental treatments?Do you have any disease, condition, or problem not listed above that you think we should know about?Women only: Are you pregnant?Women only: Are you nursing?Are you willing to spend 15 minutes a day to keep your teeth for a lifetime?* Yes No On a scale of 1 to 5, how nervous are you about dental treatments?* 1 - not nervous at all 2 3 - somewhat nervous 4 5- extremely nervous I understand the above information is necessary to provide me with dental care in a safe manner. I have answered all questions truthfully and to the best of my knowledge. I consent to your obtaining, from other practitioners who are currently treating or have treated me such further information as may be necessary for providing me with proper treatment and care.Consenting Signature*By entering your name here, you consent that the above information is correct to your knowledge.DateDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please be advised that our office policy is not to accept assignment of benefits as payment for accounts. MedicationsListMedication NameDoseFrequency If you are unable to fill out this form, please bring your medicine bottles with you to your appointment so that we can assist you in completing this information. Alternatively, with your permission, we can call your pharmacy to request a list of your current medications. Supplement UseListSupplementDoseBrandFrequency (i.e., once daily)Duration (length of intake) Dr. Fritz and Dr. Schuldt are committed to providing their patients with evidence-based care. In doing so, there may be research questions that they would like to answer using data collected during your visit to improve future patient care. Please know that in using such information your personal identity would never be revealed. Please check this box if you allow us to use your anonymized information in a future research study. Your decision will in no way impact the care you receive. Dental HistoryHow often do you go for dental cleanings?* Every 3 months Every 6 months Every 9 months Once per year Other When was your last dental cleaning?*Has there ever been a lapse of 5 years or more in your dental care?* Yes No Do you have a history of (check all that apply): Previous Periodontal Therapy Family History of Periodontal Disease Previous Orthodontic Treatment Other Relevant Dental History Home Care RoutineToothbrushing* Electric Toothbrush Manual Toothbrush How many times per day do you brush your teeth?*Interdental Care* String Floss Interdental Brushes Floss Piks Soft Piks Water Pik Other None How many times per day do you use interdental aides?*Oral ConditionDo you experience any of the following? Check all that apply* Bleeding Red, Swollen, or Receding Gums Dry Mouth Sensitivity to Temperature or Dental Cleaning Bad Taste/Bad Breath Loose Teeth Shifting Teeth Clenching/Grinding Other None Do you wear a night guard?* Yes No If so, for how many years have you worn a night guard? CDAnet Patient Information Form - Insurance InformationIs this an accident claim? Yes No Accident Claim NumberPRIMARY INSURANCE INFORMATIONName of PatientName of Policy HolderPolicy Holder's Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insurance CompanyPlan/Policy/Group NumberSubscriber/Certificate NumberPlace of EmploymentRelationship of Patient to Policy Holder Self Dependant Spouse SECONDARY INSURANCE INFORMATIONName of PatientName of Policy HolderPolicy Holder's Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insurance CompanyPolicy/Group NumberSubscriber/Certificate NumberPlace of EmploymentRelationship of patient to policy holder Dependant Spouse I authorize release to my dental benefits plan administrator, information contained in claims submitted electronically. I also understand that the office of Dr. Peter Fritz and Dr. Luisa Schuldt is a non-assignment office, meaning that all reimbursement cheques will be sent to the insurance subscriber, and that I am personally responsible for payment of my account. Consenting Signature*By entering your name here, you consent to our Office Policies as they are outlined above.DateDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 For Collection, Use and Disclosure of Personal Information Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We are as open and transparent as possible about the way that we handle your personal information. In this office, Dr. Fritz acts as the Privacy Information Officer. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. In this document, we have outlined what our office is doing to ensure that: Only absolutely necessary information is collected; We only share your information to your other health care providers with your consent; Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols; Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario (RCDSO) and the law. Please, do not hesitate to discuss our policies with any member of our office staff. How our Office Collects, Uses and Discloses Personal Patient Information This office will collect, use and disclose information for the following purposes: To deliver safe and efficient patient care; To identify and to ensure continuous high quality service; To assess your health needs; To advise you of treatment options; To establish and maintain communication with you; To allow us to efficiently follow-up for treatment, care and finances; To complete and submit dental claims for third party adjudication and payment; To comply with legal and regulatory requirements, including the delivery of patient information and records to the RCDSO in a timely fashion, when required, according to the provisions of the Regulated Health Professionals Act; To comply with agreements/undertakings entered into voluntarily by the member with the RCDSO, including the delivery and/or review of patient information and records to the College in a timely fashion for regulatory and monitoring purposes; To deliver information and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any; To prepare materials for the Health Professions Appeal and Review Board (HPARB); To invoice for goods and services; To process credit card payments; To collect unpaid accounts; To comply with all regulatory requirements and the law. By signing below, I have agreed and given my informed consent to the collection, use and/or disclosure of my personal information for the purposes listed above. If a new purpose arises for the use and/or disclosure of my personal information, we will seek your approval and permissions in advance. Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the RCDSO fulfilling its mandate under the RHPA, and for the defence of a legal issue. Our office will not under any condition supply your insurer with your confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate. You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision and the process. I have reviewed the Office Privacy Act that explains how Dr. Peter C. Fritz Periodontal Wellness and Implant Surgery will use my personal information and the steps this office is taking to protect my information. I know that the office has a Privacy Code and I can ask to see the Code at any time. I agree that Dr. Fritz and Dr. Schuldt can collect, use and disclose personal information about me as set out in the information about the office’s privacy policies.Name* First Last DateDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
