New Patient Medical History

Help us learn a little more about you!

A PDF version of this form can be downloaded below or come to your consult 30 minutes early and we can help you fill out the forms in person.

New Patient Medical History

Full Name*
Date of Birth (dd/mm/yyyy)*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Best Phone Number to Contact You*
Alternate Phone Number
Which number would you like to receive SMS messages to?*
- Main Phone Number
- Alternate Phone Number
- Neither
Email*
How would you like to receive appointment related correspondence?
- SMS
- Phone
- Email
Marital Status
Employer
Occupation
Emergency Contact Name*
Relationship*
Emergency Contact Phone Number*
General Dentist Name*
How did you hear about us? (Dentist, Hygienist, Friend, etc.)
Family Physician Name
Phone Number (if known)
Pharmacy
Phone Number (if known)
GENERAL HEALTH
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 or use tobacco products (vape, chewing tobacco, etc.)?*
- Yes
- No
If so, how many cigarettes/how much per day?
How many years have you used tobacco?
Are you a former smoker/user of tobacco products (vape, chewing tobacco, etc.)?*
- Yes
- No
If so, how many cigarettes/how much per day?
How many years did you use tobacco?
How long ago did you quit?
Do you smoke cannabis/use cannabis products (vape, edibles, etc.)?*
- 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?
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.
Date
MM slash DD slash YYYY
DENTAL HEALTH
How often do you go for dental cleanings?*
- Every three months
- Every six months
- Every nine months
- Once a year
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
Toothbrushing*
- 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?*
Do 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?
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
MEDICATIONS

Please list all medications that you currently taking

Medication Name	Dose	Frequency

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 USE

Please list all supplements that you currently take regularly

Supplement	Dose	Brand	Frequency (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.
INSURANCE INFORMATION
Do you have dental insurance?*
- Yes
- No
Please be advised that our office policy is not to accept assignment of benefits as payment for accounts.
Primary Insurance
Name of Patient
Name of Policy Holder
Policy Holder's Date of Birth
Insurance Company
Plan/Policy/Group Number
Subscriber/Certificate Number
Place of Employment
Relationship of Patient to Policy Holder
- Self
- Dependant
- Spouse
Secondary Insurance
Name of Patient
Name of Policy Holder
Policy Holder's Date of Birth
Insurance Company
Policy/Group Number
Subscriber/Certificate Number
Place of Employment
Relationship of patient to policy holder
- Dependant
- Spouse
Is this an accident claim?
- Yes
- No
Accident Claim Number
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.
Date
MM slash DD slash YYYY
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
Date
MM slash DD slash YYYY
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New Patient Medical History

Help us learn a little more about you!

New Patient Medical History

GENERAL HEALTH

DENTAL HEALTH

MEDICATIONS

SUPPLEMENT USE

INSURANCE INFORMATION

Numbers Speak

how can we help you?

Contact us

If you have any questions or comments please call our office to speak to one of our team members. Alternatively, you can complete our online contact form below and a member of our team will reach out to you as soon as possible.